Provider Demographics
NPI:1679517353
Name:WILLENBRING, MICHELLE ROSE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ROSE
Last Name:WILLENBRING
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:ROSE
Other - Last Name:FELTES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:407 KAYS DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1958
Mailing Address - Country:US
Mailing Address - Phone:309-454-1010
Mailing Address - Fax:309-454-1077
Practice Address - Street 1:407 KAYS DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1958
Practice Address - Country:US
Practice Address - Phone:309-454-1010
Practice Address - Fax:309-454-1077
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU81017Medicare UPIN
ILK34472Medicare PIN