Basic Information
| Provider Information | |||||||||
| NPI: | 1902982481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUALE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CNM, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1805 HENNEPIN AVE. NORTH | ||||||||
| Address2: | |||||||||
| City: | GLENCOE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208643121 | ||||||||
| FaxNumber: | 3208647877 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 HENNEPIN AVE. NORTH | ||||||||
| Address2: | GLENCOE REGIONAL HEALTH SERVICES | ||||||||
| City: | GLENCOE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208643121 | ||||||||
| FaxNumber: | 3202343295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R129912-4 | MN | N | Nursing Service Providers | Registered Nurse | 367A00000X | CNM0071 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LF0000X | 2775 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 897905700 | 05 | MN | MEDICAID |