Provider Demographics
NPI:1023841954
Name:WILSON, MICHAELA
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 PINE HAVEN SHORES RD STE 1000A
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-7812
Mailing Address - Country:US
Mailing Address - Phone:802-622-1734
Mailing Address - Fax:802-304-5401
Practice Address - Street 1:56 W TWIN OAKS TER STE 3
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7138
Practice Address - Country:US
Practice Address - Phone:802-622-1734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT86378090133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered