Provider Demographics
NPI:1003054586
Name:BALLISTER, MICHELE MARIE (DNP APRN CRNA CHSE)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:MARIE
Last Name:BALLISTER
Suffix:
Gender:F
Credentials:DNP APRN CRNA CHSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3616 BILLINGS ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-6888
Mailing Address - Country:US
Mailing Address - Phone:845-304-1597
Mailing Address - Fax:
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-822-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA289363367500000X
SC3758367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered