Provider Demographics
NPI:1255459996
Name:REARDON, MICHELE ELIZABETH (MS, RD)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:ELIZABETH
Last Name:REARDON
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 VILLAGE GREEN CIR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31411-1507
Mailing Address - Country:US
Mailing Address - Phone:912-598-7776
Mailing Address - Fax:
Practice Address - Street 1:5102 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4601
Practice Address - Country:US
Practice Address - Phone:912-356-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001158133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBKLMedicare ID - Type Unspecified