Provider Demographics
NPI:1508648882
Name:WORMACK, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WORMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6212 UPTON PL
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-9760
Mailing Address - Country:US
Mailing Address - Phone:202-819-7994
Mailing Address - Fax:
Practice Address - Street 1:3005 BLADENSBURG RD NE APT 521
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2242
Practice Address - Country:US
Practice Address - Phone:202-269-0757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant