Provider Demographics
NPI:1497947527
Name:GENGENBACH, JANICE ILEEN (RD)
Entity Type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:ILEEN
Last Name:GENGENBACH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43540 ROAD 739
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NE
Mailing Address - Zip Code:68976-1065
Mailing Address - Country:US
Mailing Address - Phone:308-472-5092
Mailing Address - Fax:308-472-5090
Practice Address - Street 1:300 E 12TH ST
Practice Address - Street 2:
Practice Address - City:COZAD
Practice Address - State:NE
Practice Address - Zip Code:69130-1505
Practice Address - Country:US
Practice Address - Phone:308-784-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE325133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered