Provider Demographics
NPI:1962120543
Name:MACKIN, MICHELLE KATHLEEN (FNP-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:MACKIN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 CROWNVIEW LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1297
Mailing Address - Country:US
Mailing Address - Phone:469-235-1487
Mailing Address - Fax:
Practice Address - Street 1:2909 MCKINNEY AVE STE B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-7413
Practice Address - Country:US
Practice Address - Phone:214-871-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1089642363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty