Provider Demographics
NPI:1366688343
Name:DWENGER, NATHAN (RD,LD/N)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:DWENGER
Suffix:
Gender:M
Credentials:RD,LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4603 WILLAMETTE CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4290
Mailing Address - Country:US
Mailing Address - Phone:407-273-8613
Mailing Address - Fax:
Practice Address - Street 1:4603 WILLAMETTE CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4290
Practice Address - Country:US
Practice Address - Phone:407-273-8613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 3907133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered