Healthcare Provider Details

I. General information

NPI: 1942475207
Provider Name (Legal Business Name): CHEYENNE WORKMAN RD CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6145 N 940 W
MIDDLETOWN IN
47356
US

IV. Provider business mailing address

778 S MORRISTOWN PIKE
GREENFIELD IN
46140-7885
US

V. Phone/Fax

Practice location:
  • Phone: 765-620-8400
  • Fax: 765-779-4010
Mailing address:
  • Phone: 765-969-2429
  • Fax: 765-779-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001827
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: