Provider Demographics
NPI:1093916611
Name:KING, HEIDI A (RD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:A
Last Name:KING
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 1:35318 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-0353
Mailing Address - Country:US
Mailing Address - Phone:317-528-4200
Mailing Address - Fax:
Practice Address - Street 1:761 45TH STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2899
Practice Address - Country:US
Practice Address - Phone:219-922-3020
Practice Address - Fax:219-922-3023
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
926769OtherADA REGISTRATION NUMBER