Provider Demographics
NPI:1265795058
Name:MAYES, MICHELLE MARIE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:MAYES
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 1:603 KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:BRACKNEY
Mailing Address - State:PA
Mailing Address - Zip Code:18812-9790
Mailing Address - Country:US
Mailing Address - Phone:570-663-2812
Mailing Address - Fax:
Practice Address - Street 1:603 KENNEDY RD
Practice Address - Street 2:
Practice Address - City:BRACKNEY
Practice Address - State:PA
Practice Address - Zip Code:18812-9790
Practice Address - Country:US
Practice Address - Phone:570-663-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1776437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist