Provider Demographics
NPI:1598556243
Name:MCTIGUE, MIKAYLA (RD)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:MCTIGUE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 DUNSTON DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-5644
Mailing Address - Country:US
Mailing Address - Phone:314-740-5125
Mailing Address - Fax:
Practice Address - Street 1:1110 DUNSTON DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-5644
Practice Address - Country:US
Practice Address - Phone:314-740-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164011635133V00000X
MO2022049496133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered