Provider Demographics
NPI:1457757510
Name:WILEY, MICHELLE LEE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LEE
Last Name:WILEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LEE
Other - Last Name:AHRENS-PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:PEDIATRIC CLINIC
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5611
Mailing Address - Country:US
Mailing Address - Phone:912-435-5555
Mailing Address - Fax:912-435-5954
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:PEDIATRIC CLINIC
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-5555
Practice Address - Fax:912-435-5954
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC047769164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse