Provider Demographics
NPI:1750965992
Name:LEBRUN, CALLIE ANNE (RD, CD)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:ANNE
Last Name:LEBRUN
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5871 RONK RD
Mailing Address - Street 2:
Mailing Address - City:DENMARK
Mailing Address - State:WI
Mailing Address - Zip Code:54208-9113
Mailing Address - Country:US
Mailing Address - Phone:920-615-2778
Mailing Address - Fax:
Practice Address - Street 1:1710 LAWRENCE DR STE 200
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9195
Practice Address - Country:US
Practice Address - Phone:920-570-6339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3612-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered