Provider Demographics
NPI:1174672216
Name:TILT, RENEE MICHELLE (RD, CSP, CD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MICHELLE
Last Name:TILT
Suffix:
Gender:F
Credentials:RD, CSP, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 LOCHAN CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-8561
Mailing Address - Country:US
Mailing Address - Phone:765-490-4808
Mailing Address - Fax:
Practice Address - Street 1:4500 LOCHAN CT
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8561
Practice Address - Country:US
Practice Address - Phone:765-490-4808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001701A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered