Provider Demographics
NPI:1215432471
Name:KUDWA, CORINNA RACHEL (MS, RDN)
Entity type:Individual
Prefix:
First Name:CORINNA
Middle Name:RACHEL
Last Name:KUDWA
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 FENNER RD
Mailing Address - Street 2:
Mailing Address - City:OVID
Mailing Address - State:MI
Mailing Address - Zip Code:48866-9546
Mailing Address - Country:US
Mailing Address - Phone:989-413-8031
Mailing Address - Fax:
Practice Address - Street 1:113 W BROADWAY ST STE 200
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2575
Practice Address - Country:US
Practice Address - Phone:989-400-1478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI329500852133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered