Provider Demographics
NPI:1093805558
Name:FEDAK, LORRAINE (MNT)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:FEDAK
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 SPRING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ST CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-8539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:WHEELING HOSPITAL INC
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-3124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV389133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVFEMT70221Medicare ID - Type Unspecified