Provider Demographics
NPI:1487893368
Name:BORGOGNONI, MERIKELLY (MS, RD, CDE)
Entity type:Individual
Prefix:
First Name:MERIKELLY
Middle Name:
Last Name:BORGOGNONI
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SPANN DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8810
Mailing Address - Country:US
Mailing Address - Phone:601-919-0972
Mailing Address - Fax:601-919-0974
Practice Address - Street 1:105 SPANN DR
Practice Address - Street 2:SUITE C
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8810
Practice Address - Country:US
Practice Address - Phone:601-919-0972
Practice Address - Fax:601-919-0974
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1042133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered