Provider Demographics
NPI:1114143948
Name:POPPEN, MICHELLE J (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:POPPEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 6TH AVE
Mailing Address - Street 2:PO BOX 997
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-2202
Mailing Address - Country:US
Mailing Address - Phone:507-372-2941
Mailing Address - Fax:507-372-7686
Practice Address - Street 1:1018 6TH AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2202
Practice Address - Country:US
Practice Address - Phone:507-372-2941
Practice Address - Fax:507-372-7686
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1173133V00000X
IA01112133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered