Provider Demographics
NPI:1053996397
Name:YOUNG, MICHELLE R (LDN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:R
Other - Last Name:GRIMSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4096
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:217-277-2253
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4096
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:217-277-2253
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007027443133V00000X
IA096391133V00000X
IL164004672133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered