Healthcare Provider Details

I. General information

NPI: 1114143948
Provider Name (Legal Business Name): MICHELLE J POPPEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 6TH AVE
WORTHINGTON MN
56187-2202
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 507-372-2941
  • Fax: 507-372-7686
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1173
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number01112
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: