Provider Demographics
NPI:1245232909
Name:OTTER, KIMBERLY M (RD LDN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:M
Last Name:OTTER
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:SWEDELL
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:935 JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4030
Mailing Address - Country:US
Mailing Address - Phone:217-228-2413
Mailing Address - Fax:217-228-2416
Practice Address - Street 1:935 JERSEY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4030
Practice Address - Country:US
Practice Address - Phone:217-228-2413
Practice Address - Fax:217-228-2416
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004029302133V00000X
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL075113OtherQUINCY HEALTH CARE MGMT.
IL000009329891OtherPRIVATE HEALTHCARE SYSTEM
IL00132009OtherBLUE CROSS BLUE SHIELD
IL000009329891OtherPRIVATE HEALTHCARE SYSTEM