Healthcare Provider Details

I. General information

NPI: 1962759852
Provider Name (Legal Business Name): JANE URAYNAR RD CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2414 KOHLER MEMORIAL DR
SHEBOYGAN WI
53081-3129
US

IV. Provider business mailing address

2414 KOHLER MEMORIAL DR
SHEBOYGAN WI
53081-3129
US

V. Phone/Fax

Practice location:
  • Phone: 920-457-4461
  • Fax:
Mailing address:
  • Phone: 920-457-4461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1717-29
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: