Provider Demographics
NPI:1871831966
Name:DETWILER, MICHELLE M (RD, LD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:DETWILER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11471 WATKINS RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8708
Mailing Address - Country:US
Mailing Address - Phone:937-243-0635
Mailing Address - Fax:
Practice Address - Street 1:11471 WATKINS RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8708
Practice Address - Country:US
Practice Address - Phone:937-243-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3607133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered