Healthcare Provider Details

I. General information

NPI: 1093422099
Provider Name (Legal Business Name): CONNER YODER NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9804 ACACIA PSGE
FORT WAYNE IN
46835-9143
US

IV. Provider business mailing address

9804 ACACIA PSGE
FORT WAYNE IN
46835-9143
US

V. Phone/Fax

Practice location:
  • Phone: 260-479-0080
  • Fax:
Mailing address:
  • Phone: 260-479-0080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MR. CONNER YODER
Title or Position: REGISTERED DIETITIAN
Credential: RDN, LD
Phone: 260-479-0080