Provider Demographics
NPI:1992045538
Name:WILBURN, MICHELLE O (NNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:O
Last Name:WILBURN
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 PROVISION PKWY
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-7912
Mailing Address - Country:US
Mailing Address - Phone:601-668-7242
Mailing Address - Fax:
Practice Address - Street 1:325 PROVISION PKWY
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-7912
Practice Address - Country:US
Practice Address - Phone:601-668-7242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860590363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care