Healthcare Provider Details

I. General information

NPI: 1225335334
Provider Name (Legal Business Name): ELLEN GWYN HERIOT RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS ELLEN GWYN WEIDNER

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 W HWY 98 NAVAL HOSPITAL
PENSACOLA FL
32512-0003
US

IV. Provider business mailing address

6000 W HWY 98 NAVAL HOSPITAL
PENSACOLA FL
32512-0003
US

V. Phone/Fax

Practice location:
  • Phone: 850-505-6412
  • Fax:
Mailing address:
  • Phone: 850-505-6412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number3601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: