Healthcare Provider Details

I. General information

NPI: 1538295605
Provider Name (Legal Business Name): PATTY PETTIT KOVACS MS, RD, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6145 N COUNTY ROAD 940 W
MIDDLETOWN IN
47356-9530
US

IV. Provider business mailing address

6145 N COUNTY ROAD 940 W
MIDDLETOWN IN
47356-9530
US

V. Phone/Fax

Practice location:
  • Phone: 765-620-8400
  • Fax: 765-779-4010
Mailing address:
  • Phone: 765-620-8400
  • Fax: 765-779-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37000036A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: