=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932642675
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY WELIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2016
-----------------------------------------------------
Last Update Date | 11/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MEDICAL PLZ
-----------------------------------------------------
City | LAKE ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63367-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-625-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1084 JOHANNA DR
-----------------------------------------------------
City | BALLWIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63021-6494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-226-6699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 2016030013
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------