Provider Demographics
NPI:1922381466
Name:MCQUEEN, MICHELLE LORRAINE (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LORRAINE
Last Name:MCQUEEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MCQUEEN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 419
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-0419
Mailing Address - Country:US
Mailing Address - Phone:601-528-9119
Mailing Address - Fax:601-528-9193
Practice Address - Street 1:975 HALL ST
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2107
Practice Address - Country:US
Practice Address - Phone:601-528-9119
Practice Address - Fax:601-528-9193
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02722269Medicaid
MS02722269Medicaid