Provider Demographics
NPI:1164169876
Name:DORTCH, MICHELLE L (A-GNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:DORTCH
Suffix:
Gender:F
Credentials:A-GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650859
Mailing Address - Street 2:DEPT 710
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0859
Mailing Address - Country:US
Mailing Address - Phone:409-772-1221
Mailing Address - Fax:
Practice Address - Street 1:2660 GULF FWY S
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6820
Practice Address - Country:US
Practice Address - Phone:940-228-6583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-14
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1073152363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health