Provider Demographics
NPI:1881357150
Name:NEIDHARDT, RAENETTE LYNN (RDN,LDN)
Entity type:Individual
Prefix:
First Name:RAENETTE
Middle Name:LYNN
Last Name:NEIDHARDT
Suffix:
Gender:F
Credentials:RDN,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 NANCY ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-3400
Mailing Address - Country:US
Mailing Address - Phone:937-418-7522
Mailing Address - Fax:
Practice Address - Street 1:BLDG 390 N LOOP ROAD
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-383-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.08548133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered