Healthcare Provider Details

I. General information

NPI: 1265031967
Provider Name (Legal Business Name): MICHELLE ALEXANDRA LA ROTTA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 NW 22ND ST
MIAMI FL
33142-7742
US

IV. Provider business mailing address

16080 S POST RD APT 203
WESTON FL
33331-3541
US

V. Phone/Fax

Practice location:
  • Phone: 954-736-8522
  • Fax:
Mailing address:
  • Phone: 954-736-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number9988
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: