Healthcare Provider Details

I. General information

NPI: 1972742146
Provider Name (Legal Business Name): MICHELLE ANNMARIE ANDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 BLACKTOP DR
FAIRBURN GA
30213-4442
US

IV. Provider business mailing address

115 BLACKTOP DR
FAIRBURN GA
30213-4442
US

V. Phone/Fax

Practice location:
  • Phone: 770-969-1125
  • Fax:
Mailing address:
  • Phone: 404-421-0542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN165519
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP165519
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number336085
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN165519
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: