Basic Information
| Provider Information | |||||||||
| NPI: | 1528601127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOSNELL | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1674 HILDA DR | ||||||||
| Address2: | |||||||||
| City: | SANDWICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605489394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477386511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1850 GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601783192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157588671 | ||||||||
| FaxNumber: | 8157585491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2019 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 209020890 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363L00000X | 209020890 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.