Provider Demographics
NPI:1164146908
Name:FAWCETT, MICHELLE LEAH (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEAH
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31493 RANCHO PUEBLO RD STE 206
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4833
Mailing Address - Country:US
Mailing Address - Phone:951-693-9678
Mailing Address - Fax:
Practice Address - Street 1:31493 RANCHO PUEBLO RD STE 206
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-4833
Practice Address - Country:US
Practice Address - Phone:951-693-9678
Practice Address - Fax:951-302-7710
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022778363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care