Provider Demographics
NPI:1477703056
Name:DIETZE, JANELLE MARIE (RD CSG LD)
Entity Type:Individual
Prefix:MRS
First Name:JANELLE
Middle Name:MARIE
Last Name:DIETZE
Suffix:
Gender:F
Credentials:RD CSG LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 GRAPHITE DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-5358
Mailing Address - Country:US
Mailing Address - Phone:254-449-0166
Mailing Address - Fax:
Practice Address - Street 1:416 N GRAY ST
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-5247
Practice Address - Country:US
Practice Address - Phone:254-449-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07397133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered