Provider Demographics
NPI:1336513118
Name:MICKO, COLETTE ROSE (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:ROSE
Last Name:MICKO
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 CARNFORTH CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-4212
Mailing Address - Country:US
Mailing Address - Phone:805-714-8723
Mailing Address - Fax:
Practice Address - Street 1:1132 CARNFORTH CT
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-4212
Practice Address - Country:US
Practice Address - Phone:805-714-8723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86032820133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered