Provider Demographics
NPI:1740614726
Name:MACON, MICHELLE AYESHA (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:AYESHA
Last Name:MACON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:AYESHA
Other - Last Name:MACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8715 W HIGHWAY 71 APT 4109
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-0036
Mailing Address - Country:US
Mailing Address - Phone:141-061-5856
Mailing Address - Fax:
Practice Address - Street 1:8715 W HIGHWAY 71 APT 4109
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-0036
Practice Address - Country:US
Practice Address - Phone:410-615-8566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR170142363LP0808X
TXAP134596363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health