Provider Demographics
NPI:1083915318
Name:WELLNITZ, KARLIE GRACE (RD CD)
Entity Type:Individual
Prefix:
First Name:KARLIE
Middle Name:GRACE
Last Name:WELLNITZ
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:KARLIE
Other - Middle Name:GRACE
Other - Last Name:SCHMIDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1969 W HART RD
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2230
Mailing Address - Country:US
Mailing Address - Phone:608-364-5011
Mailing Address - Fax:
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-364-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2011-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2253-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1018644OtherCOMMISSION ON DIETETIC REGISTRATION