Provider Demographics
NPI:1689766040
Name:REXROAD, MICHELE DAWN (RD,LD)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:DAWN
Last Name:REXROAD
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 267C
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-9755
Mailing Address - Country:US
Mailing Address - Phone:304-465-0478
Mailing Address - Fax:
Practice Address - Street 1:310 GEORGE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2653
Practice Address - Country:US
Practice Address - Phone:304-254-9022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV476133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered