Provider Demographics
NPI:1114425618
Name:KHUDEIRA, NEDA
Entity Type:Individual
Prefix:
First Name:NEDA
Middle Name:
Last Name:KHUDEIRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9405 S OKETO AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-2140
Mailing Address - Country:US
Mailing Address - Phone:773-585-0480
Mailing Address - Fax:773-585-0482
Practice Address - Street 1:8071 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-2003
Practice Address - Country:US
Practice Address - Phone:773-585-0480
Practice Address - Fax:773-585-0482
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007233133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164.007233OtherLICENSED DIETITAN NUTRITIONIST