Healthcare Provider Details

I. General information

NPI: 1134596802
Provider Name (Legal Business Name): MICHELLE LYNN PENDLETON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE LYNN PHILLIPE ARNP

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851042 US HIGHWAY 17
YULEE FL
32097-2845
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-225-3824
  • Fax: 904-390-7440
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN280179
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9238670
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9238670
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: