Basic Information
| Provider Information | |||||||||
| NPI: | 1104583657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVID | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6115 HICKORY GROVE RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282154207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045324262 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6115 HICKORY GROVE RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282154207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045324262 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2021 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 213400 | NC | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.