Provider Demographics
NPI:1104334077
Name:JENNINGS, MICHELLE NICOLA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLA
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WOODMONT BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-5250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17674 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2478
Practice Address - Country:US
Practice Address - Phone:623-281-3001
Practice Address - Fax:480-906-2180
Is Sole Proprietor?:No
Enumeration Date:2018-01-13
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20124363LA2200X
NC5010178363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health