Healthcare Provider Details

I. General information

NPI: 1538798707
Provider Name (Legal Business Name): MADELINE RUNYAN RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1815
US

IV. Provider business mailing address

166 MADISON AVE
URBANA OH
43078-1454
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-3000
  • Fax:
Mailing address:
  • Phone: 937-508-7544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.09087
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: