Provider Demographics
NPI:1336724541
Name:BAKER, SELENA LAUREN (RDN, LD)
Entity Type:Individual
Prefix:MS
First Name:SELENA
Middle Name:LAUREN
Last Name:BAKER
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 PERRINE ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-1446
Mailing Address - Country:US
Mailing Address - Phone:765-337-2093
Mailing Address - Fax:
Practice Address - Street 1:5165 MCCARTY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8764
Practice Address - Country:US
Practice Address - Phone:765-838-7493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003070A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN37003070AOtherINDIANA PROFESSIONAL LICENSING AGENCY MEDICAL LICENSING BOARD OF INDIANA
984074OtherCOMMISSION ON DIETETIC REGISTRATION