Provider Demographics
NPI:1548698897
Name:MEMMO, MICHELE (MS, RD, CDN)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:MEMMO
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1235
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14151-1235
Mailing Address - Country:US
Mailing Address - Phone:716-983-2270
Mailing Address - Fax:
Practice Address - Street 1:812 TIFFT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-1815
Practice Address - Country:US
Practice Address - Phone:716-983-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008415133V00000X
MDDX3743133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
471184602Medicare PIN