Provider Demographics
NPI:1205498243
Name:GLORIOSO, MICHELLE MASSAD (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MASSAD
Last Name:GLORIOSO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST STE 500
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2027
Practice Address - Country:US
Practice Address - Phone:601-352-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-29
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903388363L00000X
MSF06191268363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty