Provider Demographics
NPI:1255668968
Name:PIERCE, MICHELE C (PA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:C
Last Name:PIERCE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:KACZMARCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:17 CORAM RD UNIT 2A
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4074
Mailing Address - Country:US
Mailing Address - Phone:203-213-1881
Mailing Address - Fax:
Practice Address - Street 1:60 WESTWOOD AVE STE 314
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2460
Practice Address - Country:US
Practice Address - Phone:203-574-3007
Practice Address - Fax:203-573-1739
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1255668968OtherANTHEM
CT1255668968OtherANTHEM