Provider Demographics
NPI:1366626897
Name:IRVIN, MICHELLE R (RD CDE)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:IRVIN
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:R
Other - Last Name:LUNDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD CDE
Mailing Address - Street 1:7 HIGATE LN
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-1005
Mailing Address - Country:US
Mailing Address - Phone:402-612-4097
Mailing Address - Fax:
Practice Address - Street 1:7 HIGATE LN
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1005
Practice Address - Country:US
Practice Address - Phone:402-612-4097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001790133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE275067Medicare PIN