Provider Demographics
NPI:1891013082
Name:KOONTZ, ELAINE M (RD, LDN)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:M
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL PARK
Mailing Address - Street 2:WHEELING HOSPITAL INC
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6379
Mailing Address - Country:US
Mailing Address - Phone:304-242-9355
Mailing Address - Fax:304-243-2948
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:WHEELING HOSPITAL INC
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6379
Practice Address - Country:US
Practice Address - Phone:304-242-9355
Practice Address - Fax:304-243-2948
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV627OtherSTATE LICENSE