Provider Demographics
NPI:1679045645
Name:TAYLOR, RENEE ANNETTE (NDTR)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:ANNETTE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1857
Mailing Address - Country:US
Mailing Address - Phone:608-873-5651
Mailing Address - Fax:
Practice Address - Street 1:400 N MORRIS ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1857
Practice Address - Country:US
Practice Address - Phone:608-873-5651
Practice Address - Fax:608-873-5748
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-01
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI848559136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered