Provider Demographics
NPI:1265817761
Name:JOSE-MARCELO, MICHELLE L (CRNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:JOSE-MARCELO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:JOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8141
Mailing Address - Fax:410-328-0177
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-8141
Practice Address - Fax:410-328-0177
Is Sole Proprietor?:No
Enumeration Date:2015-07-25
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR161786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD574009600Medicaid
MDS062-0599OtherCAREFIRST BC/BS
MD436280ZCEAMedicare PIN