Provider Demographics
NPI:1982255923
Name:FALLER, MICHELLE A (NP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:FALLER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19708 78TH PL
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-7722
Mailing Address - Country:US
Mailing Address - Phone:229-251-8229
Mailing Address - Fax:
Practice Address - Street 1:340 NW COMMERCE DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4709
Practice Address - Country:US
Practice Address - Phone:386-719-9334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily