Provider Demographics
NPI:1306157821
Name:PHANEUF, MIKELANNE CHRISTINE (RD)
Entity type:Individual
Prefix:MRS
First Name:MIKELANNE
Middle Name:CHRISTINE
Last Name:PHANEUF
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 1:111 OSBORNE ST
Mailing Address - Street 2:MEDICAL ARTS CENTER, 2ND FLOOR
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6000
Mailing Address - Country:US
Mailing Address - Phone:203-739-7131
Mailing Address - Fax:
Practice Address - Street 1:111 OSBORNE ST
Practice Address - Street 2:MEDICAL ARTS CENTER, 2ND FLOOR
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6000
Practice Address - Country:US
Practice Address - Phone:203-739-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000693133V00000X
CT814055133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered