Provider Demographics
NPI:1578104899
Name:MCINTOSH, MICHELE YVETTE
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:YVETTE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MICHELE
Other - Middle Name:YVETTE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:10902 OLD PRINCESS ANNE RD
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-2940
Practice Address - Country:US
Practice Address - Phone:410-651-4040
Practice Address - Fax:888-843-8455
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR161190363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid