Provider Demographics
NPI:1154981389
Name:PADEN, REBECCA (RD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PADEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 INDIAN VILLAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-1413
Mailing Address - Country:US
Mailing Address - Phone:260-715-3613
Mailing Address - Fax:
Practice Address - Street 1:1315 DIRECTORS ROW STE 210
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-1284
Practice Address - Country:US
Practice Address - Phone:260-484-6818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002271133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered