Provider Demographics
NPI:1689901282
Name:MANN, MICHELLE DENISE (PAA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DENISE
Last Name:MANN
Suffix:
Gender:F
Credentials:PAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 235019
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5019
Mailing Address - Country:US
Mailing Address - Phone:334-279-1450
Mailing Address - Fax:334-395-4110
Practice Address - Street 1:3100 KEMBLE AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4211
Practice Address - Country:US
Practice Address - Phone:800-232-5703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055345064367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant