Provider Demographics
NPI:1659531945
Name:LARUE, MICHELLE YVONNE (CSA)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:YVONNE
Last Name:LARUE
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4653 POND LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5618
Mailing Address - Country:US
Mailing Address - Phone:470-306-1985
Mailing Address - Fax:
Practice Address - Street 1:4653 POND LN
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5618
Practice Address - Country:US
Practice Address - Phone:770-330-5549
Practice Address - Fax:678-615-2993
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2632363AS0400X
246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant