Provider Demographics
NPI:1275569295
Name:WILKINSON, KAREN S (MS,RD,LD,CD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:S
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:MS,RD,LD,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 FLAGSTAFF CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4417
Mailing Address - Country:US
Mailing Address - Phone:260-489-9009
Mailing Address - Fax:260-489-5057
Practice Address - Street 1:4210 FLAGSTAFF CV
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4417
Practice Address - Country:US
Practice Address - Phone:260-489-9009
Practice Address - Fax:260-489-5057
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD 2341133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWIM502481Medicare ID - Type UnspecifiedMEMBER NO.
IN213960BMedicare ID - Type UnspecifiedMEMBER NO