Healthcare Provider Details

I. General information

NPI: 1053158626
Provider Name (Legal Business Name): JONI THILAVONG RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 HELMBRIGHT DR
COLUMBUS OH
43230-3258
US

IV. Provider business mailing address

229 HELMBRIGHT DR
COLUMBUS OH
43230-3258
US

V. Phone/Fax

Practice location:
  • Phone: 614-657-6849
  • Fax:
Mailing address:
  • Phone: 614-657-6849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number5263
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: