Provider Demographics
NPI:1255947388
Name:HAYWOOD, MICHELLE VICTORIA (FNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:VICTORIA
Last Name:HAYWOOD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3004
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-0004
Mailing Address - Country:US
Mailing Address - Phone:443-726-3448
Mailing Address - Fax:
Practice Address - Street 1:3910 5TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-2036
Practice Address - Country:US
Practice Address - Phone:443-726-3448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR208980363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty