Provider Demographics
NPI:1558794164
Name:WOMACK, MEGHAN (RD, LD)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:WOMACK
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 1:1902 W KOCH ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-4039
Mailing Address - Country:US
Mailing Address - Phone:505-793-2826
Mailing Address - Fax:
Practice Address - Street 1:14 S WILLSON AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6232
Practice Address - Country:US
Practice Address - Phone:406-219-8462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-NUTR-LIC-49830133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered