Healthcare Provider Details

I. General information

NPI: 1689581084
Provider Name (Legal Business Name): SOPHIA GRACE MICHIELS RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SOPHIA GRACE OWENS RDN, LDN

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 S WICKENS ST
BLOOMINGTON IN
47403-4595
US

IV. Provider business mailing address

3751 S WICKENS ST
BLOOMINGTON IN
47403-4595
US

V. Phone/Fax

Practice location:
  • Phone: 985-249-8474
  • Fax:
Mailing address:
  • Phone: 985-249-8474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4131
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37004692A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: