Provider Demographics
NPI:1710369400
Name:HERGERT, KRYSTLE LEE (RD, LD)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:LEE
Last Name:HERGERT
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:SILVIS
Mailing Address - State:IL
Mailing Address - Zip Code:61282
Mailing Address - Country:US
Mailing Address - Phone:309-792-1507
Mailing Address - Fax:309-792-1518
Practice Address - Street 1:2001 5TH STREET
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282
Practice Address - Country:US
Practice Address - Phone:309-792-1507
Practice Address - Fax:309-792-1518
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006134133V00000X
IA002045133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered