Provider Demographics
NPI:1174703144
Name:HALECK, MICHELLE RENAEE (MS, RD,LD)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENAEE
Last Name:HALECK
Suffix:
Gender:F
Credentials:MS, RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 RISNER DR
Mailing Address - Street 2:ELLSWORTH AIR FORCE BASE
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-4704
Mailing Address - Country:US
Mailing Address - Phone:605-385-2349
Mailing Address - Fax:
Practice Address - Street 1:2450 RISNER DR
Practice Address - Street 2:ELLSWORTH AIR FORCE BASE
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4704
Practice Address - Country:US
Practice Address - Phone:605-385-2349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80312133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered