Provider Demographics
NPI:1679316145
Name:NIEMIETZ, TODD WILLIAM (RD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:WILLIAM
Last Name:NIEMIETZ
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9732 WILDERNESS BATTLE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-4336
Mailing Address - Country:US
Mailing Address - Phone:618-719-4275
Mailing Address - Fax:
Practice Address - Street 1:9732 WILDERNESS BATTLE CIR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-4336
Practice Address - Country:US
Practice Address - Phone:618-719-4275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014011385133V00000X
IL164.000000133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty