Provider Demographics
NPI:1992082804
Name:FORMOSO, MICHELLE (ARNP-C)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:FORMOSO
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14048 SW 83RD PL
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33158-1400
Mailing Address - Country:US
Mailing Address - Phone:305-467-7657
Mailing Address - Fax:
Practice Address - Street 1:6498 SW 24TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1949
Practice Address - Country:US
Practice Address - Phone:305-964-7392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-05
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9264772363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily