Provider Demographics
NPI:1922432376
Name:MCTAGUE, MICHELLE ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:MCTAGUE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SOUTHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1913
Mailing Address - Country:US
Mailing Address - Phone:845-338-3180
Mailing Address - Fax:
Practice Address - Street 1:95 SOUTHFIELD ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1913
Practice Address - Country:US
Practice Address - Phone:845-338-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272606-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse