Provider Demographics
NPI:1730682386
Name:EDWARDS, MICHELLE A (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:310 E SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2242
Practice Address - Country:US
Practice Address - Phone:920-433-6073
Practice Address - Fax:920-431-0333
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100063-8752084P0800X
MI43015083402084P0800X
390200000X
WI81341-202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
82082OtherAMERICAN BOARD OF PSYCHIATRY NEUROLOGY