Provider Demographics
NPI:1124664958
Name:LOVE, MICHAEL SHANE (C-EP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SHANE
Last Name:LOVE
Suffix:
Gender:M
Credentials:C-EP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 NATIONAL HWY
Mailing Address - Street 2:LAVALE MD 21502
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502
Mailing Address - Country:US
Mailing Address - Phone:307-729-9475
Mailing Address - Fax:301-729-9474
Practice Address - Street 1:957 NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-7356
Practice Address - Country:US
Practice Address - Phone:301-729-9475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1024667133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education