Provider Demographics
NPI:1629692736
Name:GAVIN, MICHELE M (OWNER)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:M
Last Name:GAVIN
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 OLD CANOE CREEK RD UNIT 702121
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34770-7086
Mailing Address - Country:US
Mailing Address - Phone:407-301-8804
Mailing Address - Fax:
Practice Address - Street 1:3450 KAISER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-7311
Practice Address - Country:US
Practice Address - Phone:407-301-8804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6969062376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator