Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2466 | WI |
NPI | 1619042983 |
---|---|
Provider Name | Irene Louise Parent |
First Address | Racine, WI 53405-3037 |
Second Address | Racine, WI 53405-3037 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
UO6768 | (02) | WI |