Provider Demographics
NPI:1891454815
Name:IWANICKI, COURTNEY (MS, RD, CSP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:IWANICKI
Suffix:
Gender:F
Credentials:MS, RD, CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13733 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MI
Mailing Address - Zip Code:49236-9653
Mailing Address - Country:US
Mailing Address - Phone:269-591-2464
Mailing Address - Fax:
Practice Address - Street 1:13733 ALLEN RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MI
Practice Address - Zip Code:49236-9653
Practice Address - Country:US
Practice Address - Phone:269-591-2464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric