Basic Information
Provider Information | |||||||||
NPI: | 1740427897 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VELANOVICH | ||||||||
FirstName: | LYNDA | ||||||||
MiddleName: | KINSELL | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WRIGHT | ||||||||
OtherFirstName: | LYNDA | ||||||||
OtherMiddleName: | KINSELL | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | R.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 45660 SCHOENHERR RD | ||||||||
Address2: |   | ||||||||
City: | SHELBY TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 483156033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8669963066 | ||||||||
FaxNumber: | 5865663068 | ||||||||
Practice Location | |||||||||
Address1: | 45660 SCHOENHERR RD | ||||||||
Address2: |   | ||||||||
City: | SHELBY TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 483156033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8669963066 | ||||||||
FaxNumber: | 5865663068 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/12/2009 | ||||||||
LastUpdateDate: | 01/12/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X |   |   | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 804364 | 01 | MI | COMMISSION ON DIETETIC REGISTRATION | OTHER |