Provider Demographics
NPI:1780311126
Name:MANN, MICHELLE CRYSTAL (MSN, FNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CRYSTAL
Last Name:MANN
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22026 WILSHIRE CIR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3719
Mailing Address - Country:US
Mailing Address - Phone:586-604-8089
Mailing Address - Fax:
Practice Address - Street 1:3031 COMMERCE DR STE A
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4515
Practice Address - Country:US
Practice Address - Phone:810-292-0557
Practice Address - Fax:810-292-0558
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704309421363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily