Provider Demographics
NPI:1194148049
Name:ANDERSON, MICHELLE LYNEE (ATC/L)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 GREYSTONE CT APT D
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-5715
Mailing Address - Country:US
Mailing Address - Phone:443-534-4133
Mailing Address - Fax:410-544-9455
Practice Address - Street 1:50 GREYSTONE CT APT D
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-5715
Practice Address - Country:US
Practice Address - Phone:443-534-4133
Practice Address - Fax:410-544-9455
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00003232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer