Provider Demographics
NPI:1639919632
Name:HOPPER, MICHAELA (MBA, RDN, LDN)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:HOPPER
Suffix:
Gender:
Credentials:MBA, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 BOULDER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-2096
Mailing Address - Country:US
Mailing Address - Phone:217-607-9669
Mailing Address - Fax:
Practice Address - Street 1:3703 BOULDER RIDGE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-2096
Practice Address - Country:US
Practice Address - Phone:217-607-9669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003851A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered