Provider Demographics
NPI:1609841279
Name:KING, MICHELLE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 MONTHAVEN PARK PL
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-7013
Mailing Address - Country:US
Mailing Address - Phone:859-806-3307
Mailing Address - Fax:
Practice Address - Street 1:4118 MONTHAVEN PARK PL
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-7013
Practice Address - Country:US
Practice Address - Phone:859-806-3307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P31322Medicare UPIN
KY0783604Medicare ID - Type Unspecified