Provider Demographics
NPI:1508338179
Name:MERRILL, ELIZABETH RAE (RDN)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:RAE
Last Name:MERRILL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:MRS
Other - First Name:ELLE
Other - Middle Name:RAE
Other - Last Name:MERRILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15054 LUKAS CT APT 320
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-7992
Mailing Address - Country:US
Mailing Address - Phone:616-990-7208
Mailing Address - Fax:
Practice Address - Street 1:15054 LUKAS CT APT 320
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-7992
Practice Address - Country:US
Practice Address - Phone:616-990-7208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86085592133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered