Basic Information
| Provider Information | |||||||||
| NPI: | 1578104899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINTOSH | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | YVETTE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EVANS | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | YVETTE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1978 | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218021978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107491015 | ||||||||
| FaxNumber: | 4107490654 | ||||||||
| Practice Location | |||||||||
| Address1: | 10902 OLD PRINCESS ANNE RD | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218532940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106514040 | ||||||||
| FaxNumber: | 8888438455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2019 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R161190 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 119591300 | 05 | MD | MEDICAID |