Provider Demographics
NPI:1134596802
Name:PENDLETON, MICHELLE LYNN (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:PHILLIPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:851042 US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-2845
Practice Address - Country:US
Practice Address - Phone:904-225-3824
Practice Address - Fax:904-390-7440
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN280179363L00000X
FLARNP9238670363LF0000X
FLAPRN9238670363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015603300Medicaid
FL015603300Medicaid
FLIH429YMedicare PIN