Provider Demographics
NPI:1831157395
Name:FILLMAN, MICHELLE A (LPN)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:A
Last Name:FILLMAN
Suffix:
Gender:F
Credentials:LPN
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 263
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:WI
Mailing Address - Zip Code:53594-0263
Mailing Address - Country:US
Mailing Address - Phone:800-850-5037
Mailing Address - Fax:
Practice Address - Street 1:1516 DEVALERA DR.
Practice Address - Street 2:101
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-1479
Practice Address - Country:US
Practice Address - Phone:608-348-8369
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38342200Medicaid