Provider Demographics
NPI:1558763458
Name:HAFFNER, EMILY (MS,RD,LD,CDE)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:HAFFNER
Suffix:
Gender:F
Credentials:MS,RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 VADALABENE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5630
Mailing Address - Country:US
Mailing Address - Phone:618-288-7408
Mailing Address - Fax:618-288-7418
Practice Address - Street 1:738 GALWAY DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MO
Practice Address - Zip Code:63021-7117
Practice Address - Country:US
Practice Address - Phone:109-528-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2020-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013030745133V00000X
IL164006321133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered