Healthcare Provider Details

I. General information

NPI: 1558238311
Provider Name (Legal Business Name): MICHAELA CAMPBELL RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2025
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4278 DUDLEY RD
MANTUA OH
44255-9475
US

IV. Provider business mailing address

4278 DUDLEY RD
MANTUA OH
44255-9475
US

V. Phone/Fax

Practice location:
  • Phone: 212-165-7136
  • Fax:
Mailing address:
  • Phone: 212-165-7136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.09884
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: