Provider Demographics
NPI:1104813229
Name:MINNICK, MICHELLE C (ARNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:MINNICK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4741 NW 8TH AVE
Mailing Address - Street 2:STE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-5510
Mailing Address - Country:US
Mailing Address - Phone:352-374-9790
Mailing Address - Fax:352-337-0744
Practice Address - Street 1:4741 NW 8TH AVE
Practice Address - Street 2:STE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-5510
Practice Address - Country:US
Practice Address - Phone:352-374-9790
Practice Address - Fax:352-337-0744
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL83359-2363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S62092Medicare UPIN
FLE1148YMedicare ID - Type Unspecified