Provider Demographics
NPI:1043522048
Name:HENICO, RENEE (RD CD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:HENICO
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6145 NORTH CR 940 WEST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47356-9530
Mailing Address - Country:US
Mailing Address - Phone:765-620-8400
Mailing Address - Fax:765-779-4010
Practice Address - Street 1:6145 NORTH CR 940 WEST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:IN
Practice Address - Zip Code:47356-9530
Practice Address - Country:US
Practice Address - Phone:765-620-8400
Practice Address - Fax:765-779-4010
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002017A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered