Provider Demographics
NPI:1629232970
Name:WELLS, HEIDI MARIE (RD CSSD LD)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:MARIE
Last Name:WELLS
Suffix:
Gender:F
Credentials:RD CSSD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 JAYHAWK DR
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67025-9174
Mailing Address - Country:US
Mailing Address - Phone:316-540-6054
Mailing Address - Fax:
Practice Address - Street 1:546 JAYHAWK DR
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:KS
Practice Address - Zip Code:67025-9174
Practice Address - Country:US
Practice Address - Phone:316-540-6054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1253133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200366290BMedicaid
KS110173010OtherMEDICARE