Provider Demographics
NPI:1598307407
Name:VALENTINE, MADELYN ELAINE (RDN)
Entity Type:Individual
Prefix:MISS
First Name:MADELYN
Middle Name:ELAINE
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2088 MEMORIAL DR APT 110
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-5302
Mailing Address - Country:US
Mailing Address - Phone:920-676-9513
Mailing Address - Fax:
Practice Address - Street 1:311 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2145
Practice Address - Country:US
Practice Address - Phone:715-526-2822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86107934133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered