Provider Demographics
NPI:1750651154
Name:TROUTNER, MIRIAM E (RD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:E
Last Name:TROUTNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 W WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-9762
Mailing Address - Country:US
Mailing Address - Phone:217-876-5370
Mailing Address - Fax:217-876-5375
Practice Address - Street 1:241 W WEAVER RD
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-9762
Practice Address - Country:US
Practice Address - Phone:217-876-5370
Practice Address - Fax:217-876-5375
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered