Provider Demographics
NPI:1356010334
Name:THELEN, GEORGIA
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:THELEN
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 1:9364 HAVERSTICK RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9364 HAVERSTICK RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1318
Practice Address - Country:US
Practice Address - Phone:989-640-3315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist