Provider Demographics
NPI:1689927808
Name:WEIS, IVY MARIE (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:IVY
Middle Name:MARIE
Last Name:WEIS
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:MARIE
Other - Last Name:KULAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1453 HOPE WAY
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-3140
Mailing Address - Country:US
Mailing Address - Phone:615-893-9390
Mailing Address - Fax:
Practice Address - Street 1:1453 HOPE WAY
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-3140
Practice Address - Country:US
Practice Address - Phone:615-893-9390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1043566133V00000X
TN2542133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist