Provider Demographics
NPI:1619371135
Name:PEARSON, MICHELLE (RD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PEARSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 PAULINE DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-8889
Mailing Address - Country:US
Mailing Address - Phone:859-475-8345
Mailing Address - Fax:
Practice Address - Street 1:209 PAULINE DR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-8889
Practice Address - Country:US
Practice Address - Phone:859-986-1259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH86020603133V00000X
KY163411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered