Provider Demographics
NPI:1154401826
Name:MARDOCK, MICHELLE ANNE (RD)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ANNE
Last Name:MARDOCK
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:CMR 442 BOX 472
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09042
Mailing Address - Country:DE
Mailing Address - Phone:01766-581-8291
Mailing Address - Fax:
Practice Address - Street 1:U.S. ARMY MEDDAC, HEIDELBERG
Practice Address - Street 2:CMR 442
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09042-0130
Practice Address - Country:DE
Practice Address - Phone:0622-117-2747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06100133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered