Provider Demographics
NPI:1477030914
Name:ROSARIO, MICHELLE (RD, MHDN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROSARIO
Suffix:
Gender:F
Credentials:RD, MHDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0589
Mailing Address - Country:US
Mailing Address - Phone:928-729-8805
Mailing Address - Fax:928-729-8198
Practice Address - Street 1:FORT DEFIANCE INDIAN HOSPITAL BOARD, INC.
Practice Address - Street 2:CORNER OF ROUTE N12 AND N7
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8805
Practice Address - Fax:928-729-8198
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1013817133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered