Provider Demographics
NPI:1841002235
Name:MOSS, JUSTINE (RD)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:MOSS
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 1:74605 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:IRON RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54847-5712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74605 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:IRON RIVER
Practice Address - State:WI
Practice Address - Zip Code:54847-5712
Practice Address - Country:US
Practice Address - Phone:218-391-9853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered