Provider Demographics
NPI:1164466900
Name:BURNS, PEI ENG (RD CD)
Entity Type:Individual
Prefix:
First Name:PEI
Middle Name:ENG
Last Name:BURNS
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 1:4210 FLAGSTAFF CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4417
Mailing Address - Country:US
Mailing Address - Phone:260-489-9009
Mailing Address - Fax:260-489-5057
Practice Address - Street 1:4210 FLAGSTAFF CV
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4417
Practice Address - Country:US
Practice Address - Phone:260-489-9009
Practice Address - Fax:260-489-5057
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000012A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN213960AMedicare ID - Type UnspecifiedMEMBER NO