Provider Demographics
NPI:1801981543
Name:HOOVER, MICHELLE DENISE (MA, RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DENISE
Last Name:HOOVER
Suffix:
Gender:F
Credentials:MA, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 BLACK OAK LN
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-7034
Mailing Address - Country:US
Mailing Address - Phone:618-334-0402
Mailing Address - Fax:618-659-3948
Practice Address - Street 1:3540 BLACK OAK LN
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-7034
Practice Address - Country:US
Practice Address - Phone:618-334-0402
Practice Address - Fax:618-659-3948
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001023440133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO060811170911448Medicaid