Provider Demographics
NPI:1578371571
Name:ANDERSON, MICKINZIE ALLISON (MS, RD, CSSD, SNS)
Entity type:Individual
Prefix:
First Name:MICKINZIE
Middle Name:ALLISON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS, RD, CSSD, SNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12030 DONNER PASS RD STE 1-924
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-0449
Mailing Address - Country:US
Mailing Address - Phone:509-370-2371
Mailing Address - Fax:
Practice Address - Street 1:12030 DONNER PASS RD STE 1-924
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-0449
Practice Address - Country:US
Practice Address - Phone:509-370-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-21
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86057266133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered