Provider Demographics
NPI:1295184414
Name:MEEGAN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MEEGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PROVIDENT DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3377
Mailing Address - Country:US
Mailing Address - Phone:574-372-7890
Mailing Address - Fax:574-372-7891
Practice Address - Street 1:1500 PROVIDENT DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3377
Practice Address - Country:US
Practice Address - Phone:574-372-7890
Practice Address - Fax:574-372-7891
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001746133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered