Provider Demographics
NPI:1528758695
Name:DALE, MICHELLE CARMEN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CARMEN
Last Name:DALE
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:PO BOX 364
Mailing Address - Street 2:
Mailing Address - City:ST MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-0364
Mailing Address - Country:US
Mailing Address - Phone:928-797-9770
Mailing Address - Fax:
Practice Address - Street 1:SR 264 & HWY 191
Practice Address - Street 2:
Practice Address - City:GANADO
Practice Address - State:AZ
Practice Address - Zip Code:86505
Practice Address - Country:US
Practice Address - Phone:928-755-4586
Practice Address - Fax:928-755-4747
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZUA2022082509175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist