Provider Demographics
NPI:1316242233
Name:HOMANN, ELLEN C (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:HOMANN
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:C
Other - Last Name:SHIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 LAKE LAND BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-5283
Mailing Address - Country:US
Mailing Address - Phone:217-258-3370
Mailing Address - Fax:217-258-3379
Practice Address - Street 1:501 LAKE LAND BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-5283
Practice Address - Country:US
Practice Address - Phone:217-258-3370
Practice Address - Fax:217-258-3379
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004542133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered