Provider Demographics
NPI:1285060749
Name:WITRY, MIAGA KATHLEEN (RD)
Entity type:Individual
Prefix:
First Name:MIAGA
Middle Name:KATHLEEN
Last Name:WITRY
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 1:5109 GUILFORD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1141
Mailing Address - Country:US
Mailing Address - Phone:219-861-6154
Mailing Address - Fax:
Practice Address - Street 1:9443 E 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46235-2132
Practice Address - Country:US
Practice Address - Phone:317-890-2100
Practice Address - Fax:317-890-2171
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1060486133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered