Provider Demographics
NPI:1801079298
Name:BLITSTEIN, MICHELLE LILA (MS RD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LILA
Last Name:BLITSTEIN
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4812 CARMEL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-5131
Mailing Address - Country:US
Mailing Address - Phone:704-491-5616
Mailing Address - Fax:704-892-2212
Practice Address - Street 1:4812 CARMEL PARK DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-5131
Practice Address - Country:US
Practice Address - Phone:704-491-5616
Practice Address - Fax:704-442-6360
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-09
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001566133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2993129OtherMRCE NC PTAN
NC142T8OtherBCBS NORTH CAROLINA