Provider Demographics
NPI:1417316340
Name:IVY, MICHELLE (MS, RDN,LD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:IVY
Suffix:
Gender:F
Credentials:MS, RDN,LD
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:HUYNH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3637 CAPSTONE LN
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-7742
Mailing Address - Country:US
Mailing Address - Phone:432-653-2102
Mailing Address - Fax:
Practice Address - Street 1:3637 CAPSTONE LN
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-7742
Practice Address - Country:US
Practice Address - Phone:432-653-2102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-20
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX086033574133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered