Provider Demographics
NPI:1346261864
Name:MCLEOD, MICHELE FONTENELLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:FONTENELLE
Last Name:MCLEOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1211 BEXLEY CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-4643
Mailing Address - Country:US
Mailing Address - Phone:601-947-7334
Mailing Address - Fax:228-396-1835
Practice Address - Street 1:967 CEDAR LAKE RD STE B
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2128
Practice Address - Country:US
Practice Address - Phone:228-396-8531
Practice Address - Fax:228-396-1835
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR645982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05238388Medicaid
MS640617252002OtherTRICARE
MSR645982OtherSTATE LICENSE
MSMM1385637OtherDEA
MS05238388Medicaid