Provider Demographics
NPI:1366852329
Name:MICHAL, ELLEN (RD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MICHAL
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 1:3301 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7432
Mailing Address - Country:US
Mailing Address - Phone:919-954-3174
Mailing Address - Fax:919-954-3177
Practice Address - Street 1:3301 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7432
Practice Address - Country:US
Practice Address - Phone:919-954-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001531133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered