Healthcare Provider Details

I. General information

NPI: 1407455132
Provider Name (Legal Business Name): WOTAN NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PATRICIA AVE
ANN ARBOR MI
48103-2634
US

IV. Provider business mailing address

900 PATRICIA AVE
ANN ARBOR MI
48103-2634
US

V. Phone/Fax

Practice location:
  • Phone: 734-263-7374
  • Fax:
Mailing address:
  • Phone: 734-263-7374
  • 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: ANDREA WOTAN
Title or Position: OWNER
Credential: RDN
Phone: 734-263-7374