Individual
MRS. ROSANNAH M. MACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD,CD
Contact information
Practice address
600 EAST BLVD, NUTRITION SERVICES DEPARTMENT, ELKHART, IN 46514-2483
(574) 523-3236
(574) 296-6504
Mailing address
PO BOX 4667, SOUTH BEND, IN 46634-4667
(574) 523-3148
(574) 523-3492
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
915393
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
37001470A
STATE CERTIFICATION NUMBE
IN
01
—
915393
LICENSE
IN
Enumeration date
12/05/2006
Last updated
04/09/2009
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