Provider Demographics
NPI:1639511652
Name:MAZUROWSKI, MICHELLE (RDN,LD,LPTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MAZUROWSKI
Suffix:
Gender:F
Credentials:RDN,LD,LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11829 LUNA DEL MAR LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-4529
Mailing Address - Country:US
Mailing Address - Phone:702-580-9742
Mailing Address - Fax:
Practice Address - Street 1:4215 S GRAND CANYON DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-7172
Practice Address - Country:US
Practice Address - Phone:702-580-9742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV929429133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered