Provider Demographics
NPI:1760457600
Name:HEADLEY, MICHELLE E (M D)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 FOREST AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1726
Mailing Address - Country:US
Mailing Address - Phone:804-282-2655
Mailing Address - Fax:804-282-0676
Practice Address - Street 1:7001 FOREST AVE STE 302
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1726
Practice Address - Country:US
Practice Address - Phone:804-282-2655
Practice Address - Fax:804-282-0676
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051265207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5834490Medicaid
VA5834490Medicaid
VA110007449 - C03895Medicare PIN