Provider Demographics
NPI:1245840644
Name:YATES, MICHELLE SHANNON (MS, RD, LMNT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SHANNON
Last Name:YATES
Suffix:
Gender:F
Credentials:MS, RD, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 S 167TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-1541
Mailing Address - Country:US
Mailing Address - Phone:402-312-5717
Mailing Address - Fax:
Practice Address - Street 1:11329 P ST STE 126
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2315
Practice Address - Country:US
Practice Address - Phone:402-807-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1380133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered