Provider Demographics
NPI:1316335599
Name:PANNELL, MICHELLE (CST, LSA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:PANNELL
Suffix:
Gender:F
Credentials:CST, LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 BUILDER RD
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-4611
Mailing Address - Country:US
Mailing Address - Phone:817-675-8299
Mailing Address - Fax:
Practice Address - Street 1:2104 BUILDER RD
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-4611
Practice Address - Country:US
Practice Address - Phone:817-675-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX143701246ZS0410X
TXSA00566246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist