Provider Demographics
NPI:1639553555
Name:STURDIVANT, MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:STURDIVANT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SUMMER LAKE CV
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-7617
Mailing Address - Country:US
Mailing Address - Phone:678-363-5925
Mailing Address - Fax:
Practice Address - Street 1:95 SUMMER LAKE CV
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-7617
Practice Address - Country:US
Practice Address - Phone:678-363-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11853146L00000X
GARN163401163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic