Provider Demographics
NPI:1578189221
Name:COMERFORD, KATHLEEN (MS, CNS, LDN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:COMERFORD
Suffix:
Gender:F
Credentials:MS, CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 BROAD RIPPLE AVE STE 179
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2034
Mailing Address - Country:US
Mailing Address - Phone:317-934-0331
Mailing Address - Fax:
Practice Address - Street 1:1075 BROAD RIPPLE AVE STE 179
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2034
Practice Address - Country:US
Practice Address - Phone:317-934-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007997133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist