Provider Demographics
NPI:1952049157
Name:ELY, JEANETTE RAE (RDN)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:RAE
Last Name:ELY
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1462
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-1462
Mailing Address - Country:US
Mailing Address - Phone:360-510-2600
Mailing Address - Fax:
Practice Address - Street 1:103 FRAM STREET
Practice Address - Street 2:# 589
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833
Practice Address - Country:US
Practice Address - Phone:907-772-5730
Practice Address - Fax:907-772-3085
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1003875133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered