Provider Demographics
NPI:1114582202
Name:HARRELL, MICHELLA
Entity Type:Individual
Prefix:
First Name:MICHELLA
Middle Name:
Last Name:HARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3462 LOCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8690 AERO DR STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1759
Practice Address - Country:US
Practice Address - Phone:858-278-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-05
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAKK5745891744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty