Provider Demographics
NPI:1437865144
Name:STEPAN, MICHELLE JEAN (RD, LD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEAN
Last Name:STEPAN
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 SILVERTHORN DR
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5637
Mailing Address - Country:US
Mailing Address - Phone:612-655-6984
Mailing Address - Fax:
Practice Address - Street 1:1334 MADISON ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1423
Practice Address - Country:US
Practice Address - Phone:612-655-6984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86117599133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered