Provider Demographics
NPI:1134758196
Name:MILLER, MICHELLE ANN (MS, RD, LDN, CNSC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS, RD, LDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 I ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2839
Mailing Address - Country:US
Mailing Address - Phone:208-303-0707
Mailing Address - Fax:
Practice Address - Street 1:2827 FORT MISSOULA RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7408
Practice Address - Country:US
Practice Address - Phone:406-327-5131
Practice Address - Fax:406-327-4176
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11668066-4901133V00000X
IDD-1200133V00000X
MT118415133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered