Provider Demographics
NPI:1740242775
Name:PHELPS, ERICA L (RD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:L
Last Name:PHELPS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:L
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:15923 GROESBECK ST
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9470
Mailing Address - Country:US
Mailing Address - Phone:616-847-5357
Mailing Address - Fax:
Practice Address - Street 1:1309 SHELDON RD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2404
Practice Address - Country:US
Practice Address - Phone:616-847-5357
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN80860001Medicare ID - Type Unspecified