Healthcare Provider Details

I. General information

NPI: 1902348857
Provider Name (Legal Business Name): MICHAELA MILLER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9750
US

IV. Provider business mailing address

5950 SE 17TH AVE
PORTLAND OR
97202-5211
US

V. Phone/Fax

Practice location:
  • Phone: 503-571-4272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDD10172321
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: