Provider Demographics
NPI:1366481517
Name:COLE, LUCILLE WILCZYNSKI (LICENSED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:WILCZYNSKI
Last Name:COLE
Suffix:
Gender:F
Credentials:LICENSED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 45TH STREET
Mailing Address - Street 2:110
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2893
Mailing Address - Country:US
Mailing Address - Phone:219-922-3020
Mailing Address - Fax:219-922-3023
Practice Address - Street 1:761 45TH AVE
Practice Address - Street 2:STE. 110
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2893
Practice Address - Country:US
Practice Address - Phone:219-922-3020
Practice Address - Fax:219-922-3023
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000462A133V00000X
IL164-003231133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN499500UUUUMedicare PIN