Provider Demographics
NPI:1801027511
Name:MUZILLA, MICHELE MARIE (RD CDLD)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:MARIE
Last Name:MUZILLA
Suffix:
Gender:F
Credentials:RD CDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:986 COUNTY HIGHWAY N
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-4242
Mailing Address - Country:US
Mailing Address - Phone:330-285-2471
Mailing Address - Fax:234-702-0132
Practice Address - Street 1:5249 E TERRACE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-8339
Practice Address - Country:US
Practice Address - Phone:608-222-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5534-29133V00000X
OHLD 5579133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered