Provider Demographics
NPI:1477152783
Name:MCKEON, MICHELLE (MS, CNS, LDN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MCKEON
Suffix:
Gender:F
Credentials:MS, CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 SYCAMORE LN
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-2354
Mailing Address - Country:US
Mailing Address - Phone:201-805-8837
Mailing Address - Fax:
Practice Address - Street 1:1155 SYCAMORE LN
Practice Address - Street 2:
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430-2354
Practice Address - Country:US
Practice Address - Phone:201-805-8837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTOO1938133N00000X
133N00000X
CT001938133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist