Provider Demographics
NPI:1265484364
Name:KOONTZ, MADELYN JO (RD, LD)
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:JO
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 LAWNRIDGE ST SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-3444
Mailing Address - Country:US
Mailing Address - Phone:541-926-9216
Mailing Address - Fax:
Practice Address - Street 1:3878 BEVERLY AVE NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1349
Practice Address - Country:US
Practice Address - Phone:503-363-6065
Practice Address - Fax:503-585-3523
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered