Provider Demographics
NPI:1548922321
Name:CHURCH, HEIDI COLLEEN (MS, RD, LD)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:COLLEEN
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:MS
Other - First Name:HEIDI
Other - Middle Name:COLLEEN
Other - Last Name:SCHWARTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:1992 PATTERSON MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MEADOW BRIDGE
Mailing Address - State:WV
Mailing Address - Zip Code:25976-6914
Mailing Address - Country:US
Mailing Address - Phone:773-459-3700
Mailing Address - Fax:
Practice Address - Street 1:1992 PATTERSON MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MEADOW BRIDGE
Practice Address - State:WV
Practice Address - Zip Code:25976-6914
Practice Address - Country:US
Practice Address - Phone:773-459-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1099133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered