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NPI Code Detail

MEDICARE: MICHELLE DEJEAN RD

MEDICARE: MICHELLE DEJEAN RD
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
1133V00000XRegistered Dietitian863038

General Provider Information

NPI Number : 1508965567
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHELLE DEJEAN RD
Provider Business Mailing Address
First Line : 7664 APACHE CLIFF ST
Second Line :
City : LAS VEGAS
State : NV
Zip : 89113-3263
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4700 LAS VEGAS BLVD N
Second Line :
City : NELLIS AFB
State : NV
Zip : 89191-6600
Country : US
Telephone Number : 702-653-3679
Fax Number : 702-653-2924
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/22/2006
Last Update Date : 07/08/2007

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