Provider Demographics
NPI:1902426372
Name:WILSON, MICHELLE (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4972 BENCHMARK CENTRE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2070
Mailing Address - Country:US
Mailing Address - Phone:618-207-4366
Mailing Address - Fax:618-744-7301
Practice Address - Street 1:4972 BENCHMARK CENTRE DR STE 100
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2070
Practice Address - Country:US
Practice Address - Phone:618-207-4366
Practice Address - Fax:618-744-7301
Is Sole Proprietor?:No
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered