Provider Demographics
NPI:1730198904
Name:DE FALCO, MICHELLE MARIE (APN)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:MARIE
Last Name:DE FALCO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S WOOD ST
Mailing Address - Street 2:1855 WEST TAYLOR SUITE 1077
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-8330
Mailing Address - Fax:312-996-9723
Practice Address - Street 1:1855 W TAYLOR ST
Practice Address - Street 2:SUITE 1077
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7242
Practice Address - Country:US
Practice Address - Phone:312-996-8330
Practice Address - Fax:312-996-9723
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004659363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK37254OtherMEDICARE CMS