Provider Demographics
NPI:1023870961
Name:HENKE, MADELINE (RDN, LRD)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:HENKE
Suffix:
Gender:F
Credentials:RDN, LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 32ND AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6701
Mailing Address - Country:US
Mailing Address - Phone:701-301-1016
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-301-1016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1365133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered