Healthcare Provider Details

I. General information

NPI: 1255181202
Provider Name (Legal Business Name): MICHELLE NICOLE NOONAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21150 N TATUM BLVD APT 2074
PHOENIX AZ
85050-7208
US

IV. Provider business mailing address

21150 N TATUM BLVD APT 2074
PHOENIX AZ
85050-7208
US

V. Phone/Fax

Practice location:
  • Phone: 602-790-3693
  • Fax:
Mailing address:
  • Phone: 602-790-3693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: