Provider Demographics
NPI:1447960604
Name:TREVINO, MICHELLE (FNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TREVINO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25613 W CERENA CIR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-6825
Mailing Address - Country:US
Mailing Address - Phone:320-455-2598
Mailing Address - Fax:
Practice Address - Street 1:148 S BOLINGBROOK DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2852
Practice Address - Country:US
Practice Address - Phone:630-914-5373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.026569363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily