Provider Demographics
NPI:1619490109
Name:NEELY, MICHELLE MARIE
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARIE
Last Name:NEELY
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 1:3007 CALLE ARCO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3607
Mailing Address - Country:US
Mailing Address - Phone:949-510-9649
Mailing Address - Fax:
Practice Address - Street 1:27702 CROWN VALLEY PKWY STE I
Practice Address - Street 2:
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-0609
Practice Address - Country:US
Practice Address - Phone:949-364-1430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist