Provider Demographics
NPI:1730411737
Name:AXIUM, MICHELLE RENEE (APN-BC)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
Last Name:AXIUM
Suffix:
Gender:F
Credentials:APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1598
Mailing Address - Country:US
Mailing Address - Phone:734-686-6361
Mailing Address - Fax:
Practice Address - Street 1:9354 S ALBANY AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2420
Practice Address - Country:US
Practice Address - Phone:708-769-4758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007967363L00000X
IL209.007967363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily