Healthcare Provider Details

I. General information

NPI: 1366593220
Provider Name (Legal Business Name): MICHELLE RENAE SCHULTZ R.D.,L.D.N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE SMITH

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 HEALTH CENTER DR STE 110
MATTOON IL
61938-4607
US

IV. Provider business mailing address

1005 HEALTH CENTER DR STE 201
MATTOON IL
61938-4693
US

V. Phone/Fax

Practice location:
  • Phone: 217-238-3488
  • Fax: 217-238-3485
Mailing address:
  • Phone: 217-238-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.003540
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: