Provider Demographics
NPI:1497058473
Name:MOONEY-MICHELS, MAUREEN PATRICIA (RD, CDE)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:PATRICIA
Last Name:MOONEY-MICHELS
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MISSION BLVD
Mailing Address - Street 2:OUTPATIENT DIABETES EDUCATION PROGRAM
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2536
Mailing Address - Country:US
Mailing Address - Phone:209-223-7448
Mailing Address - Fax:209-257-7670
Practice Address - Street 1:100 MISSION BLVD
Practice Address - Street 2:OUTPATIENT DIABETES EDUCATION PROGRAM
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2536
Practice Address - Country:US
Practice Address - Phone:209-223-7448
Practice Address - Fax:209-257-7670
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
723372133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered