Provider Demographics
NPI:1043295553
Name:KWIATKOWSKI, JUDY ANN (RD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:ANN
Last Name:KWIATKOWSKI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53780 W POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-4595
Mailing Address - Country:US
Mailing Address - Phone:574-288-4965
Mailing Address - Fax:
Practice Address - Street 1:1007 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46352-0250
Practice Address - Country:US
Practice Address - Phone:219-326-1234
Practice Address - Fax:219-326-2509
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001357A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN940640AAAMedicare UPIN