Provider Demographics
NPI:1255181202
Name:NOONAN, MICHELLE NICOLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:NOONAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21150 N TATUM BLVD APT 2074
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7208
Mailing Address - Country:US
Mailing Address - Phone:602-790-3693
Mailing Address - Fax:
Practice Address - Street 1:21150 N TATUM BLVD APT 2074
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7208
Practice Address - Country:US
Practice Address - Phone:602-790-3693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty