Provider Demographics
NPI:1114912482
Name:REIDENBACH, ANN (MPH RD CD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:REIDENBACH
Suffix:
Gender:F
Credentials:MPH RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1550
Mailing Address - Country:US
Mailing Address - Phone:260-433-3877
Mailing Address - Fax:260-755-5731
Practice Address - Street 1:6522 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1550
Practice Address - Country:US
Practice Address - Phone:260-433-3877
Practice Address - Fax:260-755-5731
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000578A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1922377423OtherNPI , ORGANIZATIONAL ENTITY