Provider Demographics
NPI:1134792831
Name:STEVENSON, MICALA (NASM-CNC)
Entity type:Individual
Prefix:
First Name:MICALA
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:NASM-CNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9701 SE JOHNSON CREEK BLVD APT F303
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-3683
Mailing Address - Country:US
Mailing Address - Phone:970-739-5897
Mailing Address - Fax:
Practice Address - Street 1:48 COUNTY ROAD 250
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8848
Practice Address - Country:US
Practice Address - Phone:970-739-5897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist