Provider Demographics
NPI:1396756342
Name:MCCLUSKEY, MICHELLE (FNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:MCCLUSKEY
Suffix:
Gender:F
Credentials:FNP
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 789
Mailing Address - Street 2:
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-0789
Mailing Address - Country:US
Mailing Address - Phone:423-581-7040
Mailing Address - Fax:423-581-9563
Practice Address - Street 1:204 SHAVER DR
Practice Address - Street 2:
Practice Address - City:TALBOTT
Practice Address - State:TN
Practice Address - Zip Code:37877-8552
Practice Address - Country:US
Practice Address - Phone:423-581-7040
Practice Address - Fax:423-581-9563
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12179363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3344091Medicaid
3344091Medicare PIN
Q75848Medicare UPIN