Healthcare Provider Details

I. General information

NPI: 1043028509
Provider Name (Legal Business Name): FUEL WITH PURPOSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 12/30/2024
Certification Date: 12/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5928 CONKRIGHT LN
WEST LAFAYETTE IN
47906-8548
US

IV. Provider business mailing address

5928 CONKRIGHT LN
WEST LAFAYETTE IN
47906-8548
US

V. Phone/Fax

Practice location:
  • Phone: 405-985-1417
  • Fax:
Mailing address:
  • Phone: 405-985-1417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELAINE WANSTREET
Title or Position: SPORTS DIETITIAN
Credential: RD, CSSD
Phone: 405-985-1417