Provider Demographics
NPI:1831634187
Name:MOECKLY, BRENDA (RD, CD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MOECKLY
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 1:1000 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-1948
Mailing Address - Country:US
Mailing Address - Phone:317-718-8163
Mailing Address - Fax:317-718-8168
Practice Address - Street 1:1000 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1948
Practice Address - Country:US
Practice Address - Phone:317-718-8163
Practice Address - Fax:317-718-8168
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002311A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered