Provider Demographics
NPI:1760217590
Name:FLACK, DEBORAH (RD, LD, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:
Last Name:FLACK
Suffix:
Gender:F
Credentials:RD, LD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PENINSULA
Mailing Address - State:OH
Mailing Address - Zip Code:44264-9792
Mailing Address - Country:US
Mailing Address - Phone:330-472-6855
Mailing Address - Fax:
Practice Address - Street 1:143 MEADOW LN
Practice Address - Street 2:
Practice Address - City:PENINSULA
Practice Address - State:OH
Practice Address - Zip Code:44264-9792
Practice Address - Country:US
Practice Address - Phone:330-472-6855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH865420133V00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No376J00000XNursing Service Related ProvidersHomemaker