Provider Demographics
NPI:1760472724
Name:FEENEY, MICHELLE WILKERSON (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:WILKERSON
Last Name:FEENEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:155 HWY 50
Practice Address - Street 2:
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449
Practice Address - Country:US
Practice Address - Phone:775-589-8946
Practice Address - Fax:775-588-1354
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN001248363LF0000X, 363LF0000X
CA13308363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVFF888ZMedicare PIN
NV1760472724Medicaid
CA1760472724Medicaid
CADK172ZMedicare PIN