Provider Demographics
NPI:1952902751
Name:EDWARD, ELISE MICHELLE (RDN, CDCES)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:MICHELLE
Last Name:EDWARD
Suffix:
Gender:F
Credentials:RDN, CDCES
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:MICHELLE
Other - Last Name:CAMERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5098 SW TECHNOLOGY LOOP APT 205
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-1591
Mailing Address - Country:US
Mailing Address - Phone:520-286-0974
Mailing Address - Fax:
Practice Address - Street 1:5098 SW TECHNOLOGY LOOP APT 205
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1591
Practice Address - Country:US
Practice Address - Phone:520-286-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86090302133VN1201X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management