Healthcare Provider Details

I. General information

NPI: 1811483498
Provider Name (Legal Business Name): MICHELLE E LIPKA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRONATURAL PHYSICIANS 120 WEBSTER SQUARE RD
BERLIN CT
06037
US

IV. Provider business mailing address

PRONATURAL PHYSICIANS GROUP 120 WEBSTER SQUARE ROAD
BERLIN CT
06037
US

V. Phone/Fax

Practice location:
  • Phone: 860-879-0707
  • Fax: 860-829-0606
Mailing address:
  • Phone: 860-829-0707
  • Fax: 860-829-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number725585
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: