Provider Demographics
NPI:1841320140
Name:DRAKE, THERESA E (RD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:E
Last Name:DRAKE
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 1:483 HOGANWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:SOBIESKI
Mailing Address - State:WI
Mailing Address - Zip Code:54171-9525
Mailing Address - Country:US
Mailing Address - Phone:920-265-4641
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1165133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000371820Medicare PIN
Q16113Medicare UPIN