Provider Demographics
NPI:1437272796
Name:FAN, MICHELLE B (NP-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:B
Last Name:FAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 SWEETBRIAR LAKES DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31757-0001
Mailing Address - Country:US
Mailing Address - Phone:229-236-6630
Mailing Address - Fax:
Practice Address - Street 1:1102 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5739
Practice Address - Country:US
Practice Address - Phone:229-225-4335
Practice Address - Fax:229-225-4374
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN147926NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBHTJMedicare PIN
Q25567Medicare UPIN