Provider Demographics
NPI:1710179544
Name:BULKLEY, KRISTIN MARIE (RD, LDN)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:BULKLEY
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15728 S ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-2693
Mailing Address - Country:US
Mailing Address - Phone:815-436-8831
Mailing Address - Fax:815-436-6863
Practice Address - Street 1:15728 S ROUTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-2693
Practice Address - Country:US
Practice Address - Phone:815-436-8831
Practice Address - Fax:815-436-6863
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004687133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164004687Medicaid
ILP00186793OtherRAILROAD MEDICARE PTAN
IL164004687Medicaid