Provider Demographics
NPI:1669001863
Name:REID, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:REID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 N STOCKTON HILL RD STE B
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0507
Mailing Address - Country:US
Mailing Address - Phone:928-757-8111
Mailing Address - Fax:
Practice Address - Street 1:1741 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-0927
Practice Address - Country:US
Practice Address - Phone:928-757-7872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRNP240241363LP0808X
NY404006363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ004681Medicaid