Provider Demographics
NPI:1043712961
Name:MICHAUD, SALLY MCINTYRE (NNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:MCINTYRE
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:BROOKS
Other - Last Name:MCINTYRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 732973
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2973
Mailing Address - Country:US
Mailing Address - Phone:817-702-2450
Mailing Address - Fax:
Practice Address - Street 1:1500 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-702-1166
Practice Address - Fax:817-702-1405
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX776106363LN0000X
TXAP136876363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care