Provider Demographics
NPI:1417461203
Name:YOUNG, REGINA CHARMAIN (CD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:CHARMAIN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:C
Other - Last Name:FALZARANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CD
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:704 S WEBSTER AVE STE 501
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-6050
Practice Address - Fax:920-433-6049
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1741-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered