Provider Demographics
NPI:1083603120
Name:LIGHTNER, MICHELLE L (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:LIGHTNER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 AVON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4423
Mailing Address - Country:US
Mailing Address - Phone:910-323-1718
Mailing Address - Fax:910-323-3834
Practice Address - Street 1:1307 AVON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4423
Practice Address - Country:US
Practice Address - Phone:910-323-1718
Practice Address - Fax:910-323-3834
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2763778Medicare Oscar/Certification
NCQ48716Medicare UPIN