Provider Demographics
NPI:1952773368
Name:MUDGE-RILEY, MICHELLE
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:MUDGE-RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 FLAT CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-8992
Mailing Address - Country:US
Mailing Address - Phone:804-334-7983
Mailing Address - Fax:
Practice Address - Street 1:10500 FLAT CREEK TRL
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-8992
Practice Address - Country:US
Practice Address - Phone:804-334-7983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-24
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83934133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered