MEDICARE: KNOWINGLY NOURISHED, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist
2	133V00000X	Registered Dietitian

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	813672	OTHER		COMMISSION ON DIETETIC REGISTRATION

General Provider Information

NPI Number	:	1316562861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KNOWINGLY NOURISHED, LLC

Provider Business Mailing Address
First Line	:	6642 S LAKE SHORE DR
Second Line	:
City	:	HARBOR SPRINGS
State	:	MI
Zip	:	49740-9785
Country	:	US
Telephone Number	:	231-881-6497
Fax Number	:	231-344-6033

Provider Business Practice Location Address
First Line	:	6642 S LAKE SHORE DR # DI
Second Line	:
City	:	HARBOR SPRINGS
State	:	MI
Zip	:	49740-9785
Country	:	US
Telephone Number	:	231-881-6497
Fax Number	:	231-344-6033

Authorized Official
Title or Position	:	OWNER
Name	:	MS. NINA FEARON
Credential	:	RDN
Telephone Number	:	231-881-6497

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	06/10/2020

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Directions to “KNOWINGLY NOURISHED, LLC ” Practice Location

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