Provider Demographics
NPI:1891145892
Name:TAVARES, MICHELLE (RD)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:TAVARES
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 1:1100 AVENUE AT PORT IMPERIAL APT 910
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-6303
Mailing Address - Country:US
Mailing Address - Phone:201-704-4654
Mailing Address - Fax:
Practice Address - Street 1:1100 AVENUE AT PORT IMPERIAL APT 910
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-6303
Practice Address - Country:US
Practice Address - Phone:201-704-4654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered