Provider Demographics
NPI:1558448035
Name:EHLERS, GWEN MARIE (RD CD)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:MARIE
Last Name:EHLERS
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13898 LAYTON RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-9498
Mailing Address - Country:US
Mailing Address - Phone:574-633-4748
Mailing Address - Fax:
Practice Address - Street 1:801 E LASALLE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2814
Practice Address - Country:US
Practice Address - Phone:574-237-7514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001241A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN37001241AOtherDIETITIAN CERTIFICATION
818472OtherAM DIETETIC ASSC