Provider Demographics
NPI:1407647134
Name:SMITH, MICHELE ILENE (MACOM, LAC)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:ILENE
Last Name:SMITH
Suffix:
Gender:X
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-7882
Mailing Address - Country:US
Mailing Address - Phone:520-393-9537
Mailing Address - Fax:
Practice Address - Street 1:1927 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-3408
Practice Address - Country:US
Practice Address - Phone:520-777-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ000741171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist