Healthcare Provider Details

I. General information

NPI: 1871587451
Provider Name (Legal Business Name): LINNEA PENNYCUFF R.D., C.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINNEA NIKIRK R.D., C.D

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 S MONROE MEDICAL PARK BLVD
BLOOMINGTON IN
47403-8000
US

IV. Provider business mailing address

4011 S MONROE MEDICAL PARK BLVD
BLOOMINGTON IN
47403-8000
US

V. Phone/Fax

Practice location:
  • Phone: 812-825-1111
  • Fax:
Mailing address:
  • Phone: 812-825-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number37001516A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: