Provider Demographics
NPI:1740536614
Name:BRENNAN, MICHELLE (RDN, LD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:ETHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:210 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1898
Mailing Address - Country:US
Mailing Address - Phone:641-236-2488
Mailing Address - Fax:
Practice Address - Street 1:210 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1898
Practice Address - Country:US
Practice Address - Phone:641-236-2488
Practice Address - Fax:641-236-2044
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082307133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0169129Medicaid