Healthcare Provider Details

I. General information

NPI: 1447761366
Provider Name (Legal Business Name): ELAINE WANSTREET MED, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 JOHN R WOODEN DR
WEST LAFAYETTE IN
48907-2070
US

IV. Provider business mailing address

900 N JOHN R WOODEN DR
WEST LAFAYETTE IN
47907-2117
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: