Provider Demographics
NPI:1477514008
Name:FAELLO, MICHELLE E (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:FAELLO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 S BEVERLY GLEN BLVD
Mailing Address - Street 2:#203
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6151
Mailing Address - Country:US
Mailing Address - Phone:310-553-3105
Mailing Address - Fax:
Practice Address - Street 1:555 E HARDY ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4011
Practice Address - Country:US
Practice Address - Phone:928-336-7389
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWNT80805AMedicare ID - Type Unspecified