Provider Demographics
NPI:1659554996
Name:WAITE, JEANETTE ILA (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ILA
Last Name:WAITE
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:ILA
Other - Last Name:GREENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED DIETITIAN
Mailing Address - Street 1:1212 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1879
Mailing Address - Country:US
Mailing Address - Phone:231-672-3648
Mailing Address - Fax:231-672-3838
Practice Address - Street 1:1212 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1879
Practice Address - Country:US
Practice Address - Phone:231-672-3648
Practice Address - Fax:231-672-3838
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI573775133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN94150005OtherMEDICARE PTAN