Provider Demographics
NPI:1366744989
Name:DEENEY, MICHELLE L (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:DEENEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:823 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-449-1010
Practice Address - Fax:843-497-6171
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00248200363A00000X
SCTL2265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1079413OtherWELLCARE
SC3674348OtherUNITED
SC2101PAMedicaid
NC1366744989Medicaid
SC9987966OtherAETNA
SCP01491958OtherRAILROAD MEDICARE
NC1366744989Medicaid