Basic Information
Provider Information | |||||||||
NPI: | 1306963046 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YOUNG | ||||||||
FirstName: | MICHELE | ||||||||
MiddleName: | KATHERINE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | YOUNG | ||||||||
OtherFirstName: | MICHELE | ||||||||
OtherMiddleName: | KATHERINE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 102222 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303682222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2392748200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3402 W DR MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336076214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138753950 | ||||||||
FaxNumber: | 8138722741 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2007 | ||||||||
LastUpdateDate: | 10/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | ARNP3083942 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | APRN3083942 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 110605800 | 05 | FL |   | MEDICAID |