Provider Demographics
NPI:1679970156
Name:MENNECKE-SMITH, MICHELLE ANN (RN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:MENNECKE-SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 SOUTHERN PINES DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-1238
Mailing Address - Country:US
Mailing Address - Phone:843-796-9370
Mailing Address - Fax:
Practice Address - Street 1:552 SOUTHERN PINES DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-1238
Practice Address - Country:US
Practice Address - Phone:843-796-9370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA545057163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse