Provider Demographics
NPI:1275113144
Name:RETTELLE, MAGGIE (RD)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:
Last Name:RETTELLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 LEE ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-5401
Mailing Address - Country:US
Mailing Address - Phone:989-488-1133
Mailing Address - Fax:
Practice Address - Street 1:715 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-5382
Practice Address - Country:US
Practice Address - Phone:989-488-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered