Provider Demographics
NPI:1649594839
Name:MCCORMICK, MICHELLE (RD LDN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N HILLCREST DR APT B
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4331
Mailing Address - Country:US
Mailing Address - Phone:919-731-1222
Mailing Address - Fax:
Practice Address - Street 1:301 N HERMAN ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-2973
Practice Address - Country:US
Practice Address - Phone:919-731-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1001493133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered