Healthcare Provider Details

I. General information

NPI: 1417510496
Provider Name (Legal Business Name): ERICA WEINANDY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3221 BEACON PKWY
GRANGER IN
46530-7196
US

IV. Provider business mailing address

726 DUBLIN DR
MISHAWAKA IN
46545-3589
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-8460
  • Fax:
Mailing address:
  • Phone: 312-593-0172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1065650
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.005687
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37002468A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: