Provider Demographics
NPI:1205140613
Name:FORRESTER, MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FORRESTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 LAWRENCEVILLE SUWANEE RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3507
Mailing Address - Country:US
Mailing Address - Phone:770-338-0089
Mailing Address - Fax:770-338-0091
Practice Address - Street 1:1730 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3507
Practice Address - Country:US
Practice Address - Phone:770-338-0089
Practice Address - Fax:770-338-0091
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2052363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2052OtherSTATE LICENSE