Provider Demographics
NPI:1083857841
Name:HERNDON, KARISSA SUZANNE (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:KARISSA
Middle Name:SUZANNE
Last Name:HERNDON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 S HIGHWAY KK
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9475
Mailing Address - Country:US
Mailing Address - Phone:573-424-8064
Mailing Address - Fax:
Practice Address - Street 1:1101 CLUB VILLAGE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4410
Practice Address - Country:US
Practice Address - Phone:573-447-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009005906133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered