Provider Demographics
NPI:1861214082
Name:MICKAVICZ, BROOKE ANA (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANA
Last Name:MICKAVICZ
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:PA
Mailing Address - Zip Code:18517-1822
Mailing Address - Country:US
Mailing Address - Phone:570-702-7729
Mailing Address - Fax:
Practice Address - Street 1:530 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:PA
Practice Address - Zip Code:18517-1822
Practice Address - Country:US
Practice Address - Phone:570-702-7729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN008601133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered