Provider Demographics
NPI:1043454762
Name:AUSTIN, JULIE ANN
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:LANE/TATARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-7081
Mailing Address - Fax:616-252-0975
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9606
Practice Address - Country:US
Practice Address - Phone:616-252-7000
Practice Address - Fax:616-252-0975
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI923445133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered