Healthcare Provider Details

I. General information

NPI: 1396819363
Provider Name (Legal Business Name): MICHELLE LEIGH KOWAL AA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

PO BOX 1076
GAINESVILLE GA
30503-1076
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-7179
  • Fax: 770-534-1312
Mailing address:
  • Phone: 770-532-7179
  • Fax: 770-534-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH8781
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number9
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2012018775
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number007263
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: