Provider Demographics
NPI:1629049382
Name:MICHAEL, JILL E (APN)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:E
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-5645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1931 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-5645
Practice Address - Country:US
Practice Address - Phone:843-915-8768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3684363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVWCHKLOtherMEDICARE GROUP
NV2402636Medicaid
NV100500023OtherMEDICAID GROUP
NV3102636Medicaid
NV2402636Medicaid
P55751Medicare UPIN