Provider Demographics
NPI:1699184077
Name:HENRICKSON, MICHELLE BUIE (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BUIE
Last Name:HENRICKSON
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-638-8631
Mailing Address - Fax:704-638-8639
Practice Address - Street 1:1910 JAKE ALEXANDER BLVD W STE 201
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1165
Practice Address - Country:US
Practice Address - Phone:704-638-8631
Practice Address - Fax:704-638-8639
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered