Basic Information
| Provider Information | |||||||||
| NPI: | 1801499124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWEENEY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 ROUTE 66 FL 3 | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077532645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328070800 | ||||||||
| FaxNumber: | 2017511680 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 PROSPECT AVE | ||||||||
| Address2: | 2ND FLOOR, IMUS PEDIATRIC CENTER | ||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076010760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519965329 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2020 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86093801 | NJ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.