Provider Demographics
NPI:1588671002
Name:KIRBY, WENDY J (RD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:J
Last Name:KIRBY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 MILFORD DR
Mailing Address - Street 2:#308
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-2704
Mailing Address - Country:US
Mailing Address - Phone:440-668-3397
Mailing Address - Fax:
Practice Address - Street 1:56 MILFORD DR
Practice Address - Street 2:#308
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-2704
Practice Address - Country:US
Practice Address - Phone:440-668-3397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2015-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD5487133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSTMT74331Medicare PIN