MEDICARE: CAMILLA AMY MIRKIN MS, RD, LDN

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	ND13655	FL

General Provider Information

NPI Number	:	1548089428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLA AMY MIRKIN MS, RD, LDN

Provider Business Mailing Address
First Line	:	18331 PINES BLVD STE 254
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33029-1421
Country	:	US
Telephone Number	:	954-866-3418
Fax Number	:

Provider Business Practice Location Address
First Line	:	18331 PINES BLVD STE 254
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33029-1421
Country	:	US
Telephone Number	:	954-866-3418
Fax Number	:

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

Provider Enumeration Date	:	10/07/2024
Last Update Date	:	10/31/2024

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