Healthcare Provider Details

I. General information

NPI: 1164880746
Provider Name (Legal Business Name): KANDI DENISE DAWSON RD, CD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KANDI DENISE BACHMAN RD

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 E. DUPONT RD NUTRITION SERVICES
FORT WAYNE IN
46825
US

IV. Provider business mailing address

2520 E. DUPONT RD NUTRITION SERVICES
FORT WAYNE IN
46825
US

V. Phone/Fax

Practice location:
  • Phone: 260-416-3263
  • Fax: 260-416-3304
Mailing address:
  • Phone: 260-416-3263
  • Fax: 260-416-3304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37000663A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: