Provider Demographics
NPI:1518492065
Name:WILLETT, LORI J (DIETITIAN)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:J
Last Name:WILLETT
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2426 GRANDE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2818
Mailing Address - Country:US
Mailing Address - Phone:319-362-2921
Mailing Address - Fax:
Practice Address - Street 1:2426 GRANDE AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2818
Practice Address - Country:US
Practice Address - Phone:319-362-2921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00315133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered