Provider Demographics
NPI:1477127652
Name:KALLENBACK, MADELINE SUZANNE (MS, RDN)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:SUZANNE
Last Name:KALLENBACK
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 S SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9702
Mailing Address - Country:US
Mailing Address - Phone:260-433-1962
Mailing Address - Fax:
Practice Address - Street 1:412 S SCOTT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9702
Practice Address - Country:US
Practice Address - Phone:260-358-7180
Practice Address - Fax:260-755-5731
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered