Healthcare Provider Details

I. General information

NPI: 1891454815
Provider Name (Legal Business Name): COURTNEY IWANICKI MS, RD, CSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13733 ALLEN RD
CLINTON MI
49236-9653
US

IV. Provider business mailing address

13733 ALLEN RD
CLINTON MI
49236-9653
US

V. Phone/Fax

Practice location:
  • Phone: 269-591-2464
  • Fax:
Mailing address:
  • Phone: 269-591-2464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: