Provider Demographics
NPI:1245221605
Name:MCLANAHAN, MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:MCLANAHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8075 GATE PARKWAY WEST
Mailing Address - Street 2:STE 305
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3685
Mailing Address - Country:US
Mailing Address - Phone:904-296-2992
Mailing Address - Fax:904-296-2993
Practice Address - Street 1:8075 GATE PARKWAY WEST
Practice Address - Street 2:STE 305
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-296-2992
Practice Address - Fax:904-296-2993
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69467174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379135100Medicaid
FL379135100Medicaid