Provider Demographics
NPI:1396819363
Name:KOWAL, MICHELLE LEIGH (AA)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LEIGH
Last Name:KOWAL
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1076
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-1076
Mailing Address - Country:US
Mailing Address - Phone:770-532-7179
Mailing Address - Fax:770-534-1312
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3715
Practice Address - Country:US
Practice Address - Phone:770-532-7179
Practice Address - Fax:770-534-1312
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8781111N00000X
OK9367H00000X
MO2012018775367H00000X
GA007263367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1396819363Medicaid
MOP01089880OtherRR MCR
MO431560263OtherTRICARE
MO431560263OtherTRICARE