Provider Demographics
NPI:1396320743
Name:BURNS, MIKAELA LEARY (RD)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:LEARY
Last Name:BURNS
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 1:6121 HOLLIS ST STE 2
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2078
Mailing Address - Country:US
Mailing Address - Phone:510-587-9600
Mailing Address - Fax:510-587-9606
Practice Address - Street 1:6121 HOLLIS ST
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2077
Practice Address - Country:US
Practice Address - Phone:831-334-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN01067133VN1004X
CA86132853133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric