Provider Demographics
NPI:1407117898
Name:VONN, MICHELLE ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNE
Last Name:VONN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANNE
Other - Last Name:BRENDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5707 BEAUTY DR
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7072
Mailing Address - Country:US
Mailing Address - Phone:443-417-8472
Mailing Address - Fax:
Practice Address - Street 1:504 E RIDGEVILLE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5942
Practice Address - Country:US
Practice Address - Phone:301-703-5452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-03
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1103765OtherNCCPA