Provider Demographics
NPI:1518005537
Name:MACNEILL, JUDITH ANN (RD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:MACNEILL
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 1:149 S POOR FARM RD
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48740-9794
Mailing Address - Country:US
Mailing Address - Phone:989-724-5753
Mailing Address - Fax:
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:989-356-8058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIR618585133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION39310Medicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPY