Provider Demographics
NPI:1831314129
Name:MACEY, MICHELLE L (CRNP-PMH)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:MACEY
Suffix:
Gender:F
Credentials:CRNP-PMH
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:LEVY-CROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP-PMH
Mailing Address - Street 1:30 GREENWAY ST NW STE 5
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3557
Mailing Address - Country:US
Mailing Address - Phone:410-760-9079
Mailing Address - Fax:410-760-1121
Practice Address - Street 1:30 GREENWAY ST NW STE 5
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3557
Practice Address - Country:US
Practice Address - Phone:410-760-9079
Practice Address - Fax:410-760-1121
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR133795363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ23100Medicare UPIN