Provider Demographics
NPI:1447805312
Name:CAMERON, ALEXANDRA KATE (RDN)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:KATE
Last Name:CAMERON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4627 WILLFORD RD
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-7614
Mailing Address - Country:US
Mailing Address - Phone:989-424-7010
Mailing Address - Fax:
Practice Address - Street 1:200 GRAND AVE STE A
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9571
Practice Address - Country:US
Practice Address - Phone:989-366-9166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86114177133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI86114177OtherCOMMISSION ON DIETETIC REGISTRATION