Provider Demographics
NPI:1770847238
Name:MICHELS, MARY JO (RD, CD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JO
Last Name:MICHELS
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2462
Mailing Address - Country:US
Mailing Address - Phone:262-896-8400
Mailing Address - Fax:262-970-6670
Practice Address - Street 1:615 W MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2462
Practice Address - Country:US
Practice Address - Phone:262-896-8400
Practice Address - Fax:262-970-6670
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI836-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered