Healthcare Provider Details

I. General information

NPI: 1770714362
Provider Name (Legal Business Name): MARY ELISE KLOPFENSTEIN RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELISE HAZELWOOD RD, LD, CDE

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S WHITE ST
MOUNT PLEASANT IA
52641-2263
US

IV. Provider business mailing address

407 S WHITE ST
MOUNT PLEASANT IA
52641-2263
US

V. Phone/Fax

Practice location:
  • Phone: 319-385-6143
  • Fax: 319-385-6571
Mailing address:
  • Phone: 319-385-6143
  • Fax: 319-385-6571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number01731
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: