MEDICARE: MS. PENNY JEAN ATKINSON R.D., C.D.E

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	133V00000X	Registered Dietitian	37001912A	IN

General Provider Information

NPI Number	:	1487948733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PENNY JEAN ATKINSON R.D., C.D.E

Provider Business Mailing Address
First Line	:	14610 WATERBROOK RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-9142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4930 ILLINOIS RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5105
Country	:	US
Telephone Number	:	260-341-2923
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2011
Last Update Date	:	06/03/2011

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