Provider Demographics
NPI:1811029937
Name:HEADLEY, MICHELLE ANN (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANN
Other - Last Name:LAMBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:7901 FROST ST
Mailing Address - Street 2:EOHD DEPARTMENT KNOLLWOOD BUILDING
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2701
Mailing Address - Country:US
Mailing Address - Phone:858-939-4620
Mailing Address - Fax:858-939-4627
Practice Address - Street 1:7901 FROST ST
Practice Address - Street 2:EOHD DEPARTMENT KNOLLWOOD BUILDING
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2701
Practice Address - Country:US
Practice Address - Phone:858-939-4620
Practice Address - Fax:858-939-4627
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 17108363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN 684929OtherREGISTERED NURSE LICENSE
CANP 17108OtherNURSE PRACTITIONER