Provider Demographics
NPI:1659633311
Name:LIGHTFOOT, MICHELE D (ACNP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:D
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 ORLANDO SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-1484
Mailing Address - Country:US
Mailing Address - Phone:817-294-4568
Mailing Address - Fax:
Practice Address - Street 1:1617 HEMPHILL ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4709
Practice Address - Country:US
Practice Address - Phone:817-920-6242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX614599363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care