MEDICARE: MICHELLE E MULLEN RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	2016029096	MO

General Provider Information

NPI Number	:	1194241778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE E MULLEN RD, LD

Provider Business Mailing Address
First Line	:	6420 CLAYTON RD
Second Line	:	CLINICAL NUTRITION
City	:	RICHMOND HTS
State	:	MO
Zip	:	63117-1811
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6420 CLAYTON RD
Second Line	:
City	:	RICHMOND HTS
State	:	MO
Zip	:	63117-1811
Country	:	US
Telephone Number	:	314-768-8891
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2017
Last Update Date	:	08/16/2017

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Directions to “ MICHELLE E MULLEN RD, LD” Practice Location

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