Provider Demographics
NPI:1801187687
Name:BOALS, MICHELLE EUBANKS (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:EUBANKS
Last Name:BOALS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:EUBANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:262 DANNY THOMAS PL
Mailing Address - Street 2:MS 515
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:901-595-3006
Mailing Address - Fax:901-595-3842
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:901-595-3006
Practice Address - Fax:901-595-3842
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15713363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1526106Medicaid