Provider Demographics
NPI:1316562861
Name:KNOWINGLY NOURISHED, LLC
Entity Type:Organization
Organization Name:KNOWINGLY NOURISHED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FEARON
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:231-881-6497
Mailing Address - Street 1:6642 S LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9785
Mailing Address - Country:US
Mailing Address - Phone:231-881-6497
Mailing Address - Fax:231-344-6033
Practice Address - Street 1:6642 S LAKE SHORE DR # DI
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-9785
Practice Address - Country:US
Practice Address - Phone:231-881-6497
Practice Address - Fax:231-344-6033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
813672OtherCOMMISSION ON DIETETIC REGISTRATION