Provider Demographics
NPI:1235784687
Name:SWANN, MICHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SWANN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-3430
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1810 ELDRON BLVD SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6831
Practice Address - Country:US
Practice Address - Phone:321-434-3430
Practice Address - Fax:321-434-3432
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001381363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLP553OtherMEDICARE
FLPENDINGMedicaid