Provider Demographics
NPI:1154608578
Name:VANDERWEELE, LORI LYNN (RD, CSP)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:LYNN
Last Name:VANDERWEELE
Suffix:
Gender:F
Credentials:RD, CSP
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:L
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:269-760-8841
Mailing Address - Fax:
Practice Address - Street 1:435 IONIA AVE SW STE A210
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5161
Practice Address - Country:US
Practice Address - Phone:616-486-0385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH912475133V00000X
IN912475133VN1004X
MI912475133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric