Provider Demographics
NPI:1043495955
Name:FEDERICI, MICHELE RAE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:RAE
Last Name:FEDERICI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MICHELE
Other - Middle Name:RAE
Other - Last Name:KLESTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 CRANBERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-5216
Mailing Address - Country:US
Mailing Address - Phone:715-393-3990
Mailing Address - Fax:
Practice Address - Street 1:3301 CRANBERRY BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5216
Practice Address - Country:US
Practice Address - Phone:715-393-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2232-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant