Healthcare Provider Details

I. General information

NPI: 1588306617
Provider Name (Legal Business Name): MELANIE VICKERY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE MITUTA

II. Dates (important events)

Enumeration Date: 04/09/2022
Last Update Date: 04/09/2022
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15722 TURNER RD
LANSING MI
48906-1138
US

IV. Provider business mailing address

15722 TURNER RD
LANSING MI
48906-1138
US

V. Phone/Fax

Practice location:
  • Phone: 248-396-1627
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86117949
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: