Provider Demographics
NPI:1487745345
Name:LIDDY, MICHELLE L (APRN, CNM)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:LIDDY
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E HIBISCUS BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3155
Mailing Address - Country:US
Mailing Address - Phone:321-724-2229
Mailing Address - Fax:321-728-6688
Practice Address - Street 1:2671 HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-2605
Practice Address - Country:US
Practice Address - Phone:732-528-6999
Practice Address - Fax:732-528-3397
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9483866363L00000X, 367A00000X
NJ25ME00029900367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ML1079424OtherDRUG ENFORCEMENT ADMIN
NJ26NO10618000OtherREGISTERED PROF NURSE
NJM00007000OtherCONTROLLED DRUG SUBS REG
NJ25MD00029901OtherCNM W/ PRESCIPT AUTH.
NJ25ME00029900OtherCERT NURSE MIDWIFE