MEDICARE: SARA MARIE MICKELSON R.D., M.B.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	1062741	UT

General Provider Information

NPI Number	:	1518392893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA MARIE MICKELSON R.D., M.B.A.

Provider Business Mailing Address
First Line	:	1990 S MCCLELLAND ST APT 15
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3456
Country	:	US
Telephone Number	:	310-529-2455
Fax Number	:

Provider Business Practice Location Address
First Line	:	1990 S MCCLELLAND ST APT 15
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3456
Country	:	US
Telephone Number	:	310-529-2455
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2013
Last Update Date	:	09/05/2013

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