Provider Demographics
NPI:1922336270
Name:MCGOVERN, MICHELLE RENEE (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:MCGOVERN
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 1:402 10TH ST SE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2403
Mailing Address - Country:US
Mailing Address - Phone:319-363-1284
Mailing Address - Fax:
Practice Address - Street 1:402 10TH ST SE
Practice Address - Street 2:SUITE 700
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2403
Practice Address - Country:US
Practice Address - Phone:319-363-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01195133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered