Healthcare Provider Details

I. General information

NPI: 1619349321
Provider Name (Legal Business Name): MICHON KYSILKA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97471-6523
US

IV. Provider business mailing address

4955 28TH AVE S APT 212
FARGO ND
58104-8472
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number943
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: