Provider Demographics
NPI:1609415421
Name:SAILOR, MIKHAILA (RD)
Entity Type:Individual
Prefix:
First Name:MIKHAILA
Middle Name:
Last Name:SAILOR
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MIKHAILA
Other - Middle Name:
Other - Last Name:LICHTENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3316 CALEDON PL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-9136
Mailing Address - Country:US
Mailing Address - Phone:260-494-2918
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4160
Practice Address - Country:US
Practice Address - Phone:260-435-7995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86078420133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty