Provider Demographics
NPI:1871315333
Name:KOLODIEJ MOEHLENHOF, MARY ELLEN (RDN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:KOLODIEJ MOEHLENHOF
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 1:2717 SHOREWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:IN
Mailing Address - Zip Code:46360-2291
Mailing Address - Country:US
Mailing Address - Phone:219-871-9037
Mailing Address - Fax:
Practice Address - Street 1:2717 SHOREWOOD DR
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:IN
Practice Address - Zip Code:46360-2291
Practice Address - Country:US
Practice Address - Phone:219-871-9037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002080A133V00000X
IL164005409133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered