Provider Demographics
NPI:1649210246
Name:MADSEN, MICHELLE SHELLEY (RD,LD,CDE)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SHELLEY
Last Name:MADSEN
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:MADSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD,LD,CDE
Mailing Address - Street 1:PO BOX 500202
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-0202
Mailing Address - Country:US
Mailing Address - Phone:512-250-9140
Mailing Address - Fax:512-250-2207
Practice Address - Street 1:6500 N MOPAC
Practice Address - Street 2:BLDG III, STE 220
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731
Practice Address - Country:US
Practice Address - Phone:512-338-4500
Practice Address - Fax:512-338-4501
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT03472133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0077HCOtherBCBS
TX00502PMedicare ID - Type Unspecified
P53211Medicare UPIN