Provider Demographics
NPI:1225740830
Name:KIRKMAN, DALEENA
Entity Type:Individual
Prefix:
First Name:DALEENA
Middle Name:
Last Name:KIRKMAN
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 1:9273 HIGHWAY AA
Mailing Address - Street 2:
Mailing Address - City:BROSELEY
Mailing Address - State:MO
Mailing Address - Zip Code:63932-7109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3318
Practice Address - Country:US
Practice Address - Phone:573-686-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007010452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered