Provider Demographics
NPI:1801227467
Name:HERRICK, ABBY
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:HERRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY PARK
Mailing Address - State:MO
Mailing Address - Zip Code:63088-2530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:885 FOREST AVE
Practice Address - Street 2:
Practice Address - City:VALLEY PARK
Practice Address - State:MO
Practice Address - Zip Code:63088-2530
Practice Address - Country:US
Practice Address - Phone:314-699-4993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009015288133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered