Provider Demographics
NPI:1053891440
Name:ANDERSON, MICHELE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PMHNP-BC
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 43 MR 10202
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-3738
Mailing Address - Fax:
Practice Address - Street 1:480 OSBORNE RD NE
Practice Address - Street 2:STE 260
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55432-2866
Practice Address - Country:US
Practice Address - Phone:763-236-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6057363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health