Provider Demographics
NPI:1619570611
Name:ROGERS, MICHELLE MARIE (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:ROGERS
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 1:3402A DALY ST
Mailing Address - Street 2:
Mailing Address - City:29 PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-9467
Mailing Address - Country:US
Mailing Address - Phone:734-773-7848
Mailing Address - Fax:
Practice Address - Street 1:3402A DALY ST
Practice Address - Street 2:
Practice Address - City:29 PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-9467
Practice Address - Country:US
Practice Address - Phone:734-773-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86150243133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered