Healthcare Provider Details

I. General information

NPI: 1588731061
Provider Name (Legal Business Name): LINDA DIANE JICHA RD, CD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

1701 ROBERTS LN
ABRAMS WI
54101-9422
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-3202
  • Fax:
Mailing address:
  • Phone: 920-785-3760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2321-029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: