Provider Demographics
NPI:1124333109
Name:THEISEN, MICHELLE LAYNE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LAYNE
Last Name:THEISEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23575 HANGING OAK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78266-1757
Mailing Address - Country:US
Mailing Address - Phone:210-273-6257
Mailing Address - Fax:
Practice Address - Street 1:910 KITTYHAWK RD
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3806
Practice Address - Country:US
Practice Address - Phone:210-945-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist