Provider Demographics
NPI:1225197742
Name:LATANICK, MAUREEN R (PHD, RD, CDE)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:R
Last Name:LATANICK
Suffix:
Gender:F
Credentials:PHD, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 WILBER AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1314
Mailing Address - Country:US
Mailing Address - Phone:614-725-3248
Mailing Address - Fax:614-396-6734
Practice Address - Street 1:37 E WILSON BRIDGE RD
Practice Address - Street 2:SUITE 270
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2354
Practice Address - Country:US
Practice Address - Phone:614-396-6730
Practice Address - Fax:614-396-6734
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1235133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH63-00016OtherUNITED HEALTHCARE
OH000000113720OtherOHIO BLUE SHIELD
OH4398510OtherAETNA
OH000000113720OtherOHIO BLUE SHIELD