Provider Demographics
NPI:1609938711
Name:HINES, MICHELLE JOHNSON (RD)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:JOHNSON
Last Name:HINES
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 1:3820 W HAPPY VALLEY ROAD #141-187
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310
Mailing Address - Country:US
Mailing Address - Phone:602-770-7611
Mailing Address - Fax:
Practice Address - Street 1:2470 S VAL VISTA DR #104
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295
Practice Address - Country:US
Practice Address - Phone:602-770-7611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL878146133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered