MEDICARE: MS. LORI J. WILLETT DIETITIAN

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	00315	IA

General Provider Information

NPI Number	:	1518492065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LORI J. WILLETT DIETITIAN

Provider Business Mailing Address
First Line	:	2426 GRANDE AVE SE
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52403-2818
Country	:	US
Telephone Number	:	319-362-2921
Fax Number	:

Provider Business Practice Location Address
First Line	:	2426 GRANDE AVE SE
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52403-2818
Country	:	US
Telephone Number	:	319-362-2921
Fax Number	:

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

Provider Enumeration Date	:	04/21/2017
Last Update Date	:	04/21/2017

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