Healthcare Provider Details

I. General information

NPI: 1750161691
Provider Name (Legal Business Name): KHALIAH MCMICHAEL CAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8211
US

IV. Provider business mailing address

1379 COOPERS HAWK WAY
MIDDLEBURG FL
32068-8792
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA920
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: