Healthcare Provider Details

I. General information

NPI: 1700860012
Provider Name (Legal Business Name): MARY ANN MORGAN R. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 LINCOLNWAY
LAPORTE IN
46350-3201
US

IV. Provider business mailing address

29326 QUINN RD
NORTH LIBERTY IN
46554-9212
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-1234
  • Fax: 219-326-2509
Mailing address:
  • Phone: 574-656-8466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37000733A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: