Provider Demographics
NPI:1235305905
Name:COLE, MICHELLE DENISE (KCSA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DENISE
Last Name:COLE
Suffix:
Gender:F
Credentials:KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3240 MOUNT MORIAH AVE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-7805
Mailing Address - Country:US
Mailing Address - Phone:270-686-6168
Mailing Address - Fax:270-686-6140
Practice Address - Street 1:3240 MOUNT MORIAH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7805
Practice Address - Country:US
Practice Address - Phone:270-686-6168
Practice Address - Fax:270-686-6140
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29422363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64294226Medicaid
KY64294226Medicaid