Provider Demographics
NPI:1790468742
Name:DITTMER, MARIE (MA, RDN)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:DITTMER
Suffix:
Gender:F
Credentials:MA, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N42W22832 BEACON CT
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-1163
Mailing Address - Country:US
Mailing Address - Phone:262-422-2390
Mailing Address - Fax:
Practice Address - Street 1:N42W22832 BEACON CT
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-1163
Practice Address - Country:US
Practice Address - Phone:262-422-2390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered