Provider Demographics
NPI:1356451660
Name:WALLIN, MICHELE RENEE (MS, RD, CD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:RENEE
Last Name:WALLIN
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9347 W. CO. RD. 50 S.
Mailing Address - Street 2:
Mailing Address - City:FARMLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47340
Mailing Address - Country:US
Mailing Address - Phone:765-468-7170
Mailing Address - Fax:
Practice Address - Street 1:1700 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4568
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:765-677-3150
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN706346133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered