Provider Demographics
NPI:1902237217
Name:VINE, DEBORAH (MSAE, RD, CDE)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:VINE
Suffix:
Gender:F
Credentials:MSAE, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11725 N ILLINOIS ST
Practice Address - Street 2:SUITE 355
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3008
Practice Address - Country:US
Practice Address - Phone:317-688-4948
Practice Address - Fax:317-688-6318
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001179A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430192Medicare PIN