Provider Demographics
NPI:1972149862
Name:PERSONETTE, BAILEY (RD, CD)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:PERSONETTE
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5409 OSAGE LAKE DR APT 2A
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1288
Mailing Address - Country:US
Mailing Address - Phone:574-261-2035
Mailing Address - Fax:
Practice Address - Street 1:1540 TRINITY PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5006
Practice Address - Country:US
Practice Address - Phone:574-272-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86067213133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered