Provider Demographics
NPI:1700568060
Name:PRELLBERG, TAYLOR ASHLEY (RD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ASHLEY
Last Name:PRELLBERG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 N 124TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-3803
Mailing Address - Country:US
Mailing Address - Phone:815-651-6174
Mailing Address - Fax:
Practice Address - Street 1:2925 N 124TH ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-3803
Practice Address - Country:US
Practice Address - Phone:815-651-6174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86086704133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered