Provider Demographics
NPI:1912592585
Name:FORD, NATASHA ANTOINETTE (RD)
Entity type:Individual
Prefix:MS
First Name:NATASHA
Middle Name:ANTOINETTE
Last Name:FORD
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 1:1216 E HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3472
Mailing Address - Country:US
Mailing Address - Phone:248-884-1630
Mailing Address - Fax:
Practice Address - Street 1:1216 E. HUDSON AVE.
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-4806
Practice Address - Country:US
Practice Address - Phone:248-884-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86082067133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered