Provider Demographics
NPI:1609207992
Name:MCKENZIE, GRETA K (MS, RD)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:K
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:GRETA
Other - Middle Name:K
Other - Last Name:MELLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:13848 DEARBORN CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-7470
Mailing Address - Country:US
Mailing Address - Phone:317-373-1223
Mailing Address - Fax:
Practice Address - Street 1:13848 DEARBORN CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-7470
Practice Address - Country:US
Practice Address - Phone:317-373-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN707829133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered