Provider Demographics
NPI:1518658533
Name:MIDDENDORF, OLIVIA ROSE (RD, LD)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ROSE
Last Name:MIDDENDORF
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8520 N HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EAST DUBUQUE
Mailing Address - State:IL
Mailing Address - Zip Code:61025-9718
Mailing Address - Country:US
Mailing Address - Phone:563-690-8197
Mailing Address - Fax:
Practice Address - Street 1:1 CARDINAL WAY APT 1213
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63102-2810
Practice Address - Country:US
Practice Address - Phone:563-690-8197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA116501133V00000X
MO2022045025133V00000X
IL164.008985133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered