Healthcare Provider Details

I. General information

NPI: 1962533729
Provider Name (Legal Business Name): JANELLE R WEATHERHOLT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 MILLIS AVE
BOONVILLE IN
47601-2242
US

IV. Provider business mailing address

2321 OAKFIELD CT
WADESVILLE IN
47638-9114
US

V. Phone/Fax

Practice location:
  • Phone: 812-897-4800
  • Fax:
Mailing address:
  • Phone: 812-985-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001374A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: