Provider Demographics
NPI:1699045450
Name:SOUTH, MICHELLE MARLYS (LVN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARLYS
Last Name:SOUTH
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18285 CHINA GRADE RD SPC 3
Mailing Address - Street 2:
Mailing Address - City:BOULDER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95006-9100
Mailing Address - Country:US
Mailing Address - Phone:831-419-3116
Mailing Address - Fax:
Practice Address - Street 1:18285 CHINA GRADE RD
Practice Address - Street 2:#3
Practice Address - City:BOULDER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95006-9188
Practice Address - Country:US
Practice Address - Phone:831-419-3116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220999164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse