Provider Demographics
NPI:1487033858
Name:KING, MICHELLE MARIE (APRN)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2525
Mailing Address - Country:US
Mailing Address - Phone:203-759-3666
Mailing Address - Fax:
Practice Address - Street 1:170 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2525
Practice Address - Country:US
Practice Address - Phone:203-759-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6216363L00000X, 363LF0000X
CT095549163WC0200X, 163WE0003X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program