Provider Demographics
NPI:1679934707
Name:DIFFENDERFER, JULEA B (RD, CDE)
Entity Type:Individual
Prefix:
First Name:JULEA
Middle Name:B
Last Name:DIFFENDERFER
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:MEDPARTNERS, ATTN: MEGAN FORTNEY
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3515
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:2516 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1608
Practice Address - Country:US
Practice Address - Phone:260-458-3725
Practice Address - Fax:260-458-3726
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001035A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN260690079Medicare PIN