Provider Demographics
NPI:1164067815
Name:KING, MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:LEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1630 BARCLAY POINTE BLVD APT 9203
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-1107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:619-794-8148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-16
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
NC276301367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program