Healthcare Provider Details

I. General information

NPI: 1578843645
Provider Name (Legal Business Name): MICHELLE FEZZA LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 QUEEN ELIZABETH DR
VIRGINIA BCH VA
23452-3814
US

IV. Provider business mailing address

720 QUEEN ELIZABETH DR
VIRGINIA BEACH VA
23452-3814
US

V. Phone/Fax

Practice location:
  • Phone: 757-343-9129
  • Fax:
Mailing address:
  • Phone: 757-343-9129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002083719
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: