Healthcare Provider Details

I. General information

NPI: 1144593955
Provider Name (Legal Business Name): MICHELLE MARIE CORMIER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE CORMIER BRENNER M.D.

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5/11 BAS, 43505 A STREET 43 AREA
CAMP PENDLETON CA
92055-5534
US

IV. Provider business mailing address

PO BOX 555534
CAMP PENDLETON CA
92055-5534
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1054
  • Fax:
Mailing address:
  • Phone: 760-725-1054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: