Provider Demographics
NPI:1104838838
Name:VANICEK, JOAN GREEN (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:GREEN
Last Name:VANICEK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 VETERANS MEMORIAL DR
Mailing Address - Street 2:CTVHCS, NFS 120T
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-7451
Mailing Address - Country:US
Mailing Address - Phone:800-423-2111
Mailing Address - Fax:
Practice Address - Street 1:1901 S 1ST ST
Practice Address - Street 2:CTVHCS, NFS 120T
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7451
Practice Address - Country:US
Practice Address - Phone:254-743-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT03130133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered