Provider Demographics
NPI:1558016329
Name:HOSSACK, MICHELLE MONIQUE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MONIQUE
Last Name:HOSSACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:MONIQUE
Other - Last Name:BONE'
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:950 COMMON OAK PL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8260
Mailing Address - Country:US
Mailing Address - Phone:917-288-2642
Mailing Address - Fax:
Practice Address - Street 1:795 POPLAR RD STE 400
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2590
Practice Address - Country:US
Practice Address - Phone:770-400-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-19
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN193043363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care