Provider Demographics
NPI:1659631208
Name:DALEY, MICHELLE LISE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LISE
Last Name:DALEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:LISE
Other - Last Name:LEVESQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LEVESQUE
Mailing Address - Street 1:PSC 480 BOX 581
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96370-0006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP UNIT 5142
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368-5142
Practice Address - Country:US
Practice Address - Phone:098-960-4817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004733363AS0400X
VA0110003843363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical