Provider Demographics
NPI:1871587451
Name:PENNYCUFF, LINNEA (RD, CD)
Entity type:Individual
Prefix:
First Name:LINNEA
Middle Name:
Last Name:PENNYCUFF
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:LINNEA
Other - Middle Name:
Other - Last Name:NIKIRK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CD
Mailing Address - Street 1:4011 S MONROE MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-8000
Mailing Address - Country:US
Mailing Address - Phone:812-825-1111
Mailing Address - Fax:
Practice Address - Street 1:4011 S MONROE MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-8000
Practice Address - Country:US
Practice Address - Phone:812-825-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001516A133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN940090WWWMedicare ID - Type UnspecifiedDIETITIAN
INQ10120Medicare UPIN