Provider Demographics
NPI:1760030456
Name:MICHAEL, STEPHANIE MICHELLE (MS, RDN)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 7TH AVE # 17
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-1606
Mailing Address - Country:US
Mailing Address - Phone:808-870-3389
Mailing Address - Fax:
Practice Address - Street 1:615 7TH AVE # 17
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1606
Practice Address - Country:US
Practice Address - Phone:808-870-3389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60794582133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty