Provider Demographics
NPI:1679039986
Name:MICHALISKO, DESIRAE C (NP, CNM)
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:C
Last Name:MICHALISKO
Suffix:
Gender:F
Credentials:NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13420 N MERIDIAN ST STE 420
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1581
Mailing Address - Country:US
Mailing Address - Phone:317-582-8500
Mailing Address - Fax:
Practice Address - Street 1:13420 N MERIDIAN ST STE 420
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1581
Practice Address - Country:US
Practice Address - Phone:317-582-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367A00000X
IN09000371A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty