Provider Demographics
NPI:1275091712
Name:DAVIGNON, MICHELLE (PNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DAVIGNON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 CLAUDIA DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-8318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4645 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:BEECH ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29842-7265
Practice Address - Country:US
Practice Address - Phone:803-593-9283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN236485363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty