Provider Demographics
NPI:1245656057
Name:RICHARDSON, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:RICHARDSON
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 1:4807 PIN OAK PARK
Mailing Address - Street 2:# 224
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-2209
Mailing Address - Country:US
Mailing Address - Phone:823-831-7441
Mailing Address - Fax:
Practice Address - Street 1:7610 W HIGHWAY 71 STE F
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8239
Practice Address - Country:US
Practice Address - Phone:512-288-0859
Practice Address - Fax:512-301-4821
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX849655363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health