Provider Demographics
NPI:1518392893
Name:MICKELSON, SARA MARIE (RD, MBA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:RD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 S MCCLELLAND ST APT 15
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3456
Mailing Address - Country:US
Mailing Address - Phone:310-529-2455
Mailing Address - Fax:
Practice Address - Street 1:1990 S MCCLELLAND ST APT 15
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3456
Practice Address - Country:US
Practice Address - Phone:310-529-2455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1062741133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered