Provider Demographics
NPI:1821732322
Name:DIDNER, MICHELLE MASI
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MASI
Last Name:DIDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 NEWTOWN TPKE
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-1017
Mailing Address - Country:US
Mailing Address - Phone:203-800-1525
Mailing Address - Fax:
Practice Address - Street 1:155 NEWTOWN TPKE
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-1017
Practice Address - Country:US
Practice Address - Phone:203-800-1525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT59.002183133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT59.002183OtherCT NUTRITION LICENSE