Provider Demographics
NPI:1811483498
Name:LIPKA, MICHELLE E (RD)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:E
Last Name:LIPKA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PRONATURAL PHYSICIANS GROUP
Mailing Address - Street 2:120 WEBSTER SQUARE ROAD
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037
Mailing Address - Country:US
Mailing Address - Phone:860-829-0707
Mailing Address - Fax:860-829-0606
Practice Address - Street 1:PRONATURAL PHYSICIANS
Practice Address - Street 2:120 WEBSTER SQUARE RD
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037
Practice Address - Country:US
Practice Address - Phone:860-879-0707
Practice Address - Fax:860-829-0606
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT725585133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered