Provider Demographics
NPI:1154693091
Name:SNODGRASS, MICHELLE D (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:SNODGRASS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2093
Mailing Address - Fax:423-390-3340
Practice Address - Street 1:4848 FORT HENRY DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-3347
Practice Address - Country:US
Practice Address - Phone:423-239-5141
Practice Address - Fax:423-239-4869
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169879363LF0000X
TN16497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I502883Medicare PIN
TN103I509960Medicare PIN
VAVV9554BMedicare PIN