Provider Demographics
NPI:1134590805
Name:FACKLER, MICHELLE MILLER (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MILLER
Last Name:FACKLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ELIZABETH
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3920
Mailing Address - Country:US
Mailing Address - Phone:305-981-0600
Mailing Address - Fax:305-981-2700
Practice Address - Street 1:1801 NE 123RD ST STE 414
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-2884
Practice Address - Country:US
Practice Address - Phone:305-981-0600
Practice Address - Fax:305-981-2700
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9262797363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015843800Medicaid