Healthcare Provider Details

I. General information

NPI: 1356451660
Provider Name (Legal Business Name): MICHELE RENEE WALLIN MS, RD, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E 38TH ST
MARION IN
46953-4568
US

IV. Provider business mailing address

9347 W. CO. RD. 50 S.
FARMLAND IN
47340
US

V. Phone/Fax

Practice location:
  • Phone: 765-674-3321
  • Fax: 765-677-3150
Mailing address:
  • Phone: 765-468-7170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number706346
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: