Provider Demographics
NPI:1922209535
Name:KOSELKE, BRIDGETTE RENEE
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:RENEE
Last Name:KOSELKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10649 W 1500 S
Mailing Address - Street 2:
Mailing Address - City:WANATAH
Mailing Address - State:IN
Mailing Address - Zip Code:46390-9734
Mailing Address - Country:US
Mailing Address - Phone:219-733-9695
Mailing Address - Fax:
Practice Address - Street 1:301 W HOMER ST
Practice Address - Street 2:STE 106
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4358
Practice Address - Country:US
Practice Address - Phone:219-861-8814
Practice Address - Fax:219-861-8813
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001482A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered