Provider Demographics
NPI:1336280916
Name:WORTHY, MICHELLE L (LPN)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:L
Last Name:WORTHY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 W OSBORN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3618
Mailing Address - Country:US
Mailing Address - Phone:602-707-2415
Mailing Address - Fax:602-707-2040
Practice Address - Street 1:1102 W HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2470
Practice Address - Country:US
Practice Address - Phone:602-707-2415
Practice Address - Fax:602-707-2040
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP024466164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ007122Medicaid