Provider Demographics
NPI:1861649089
Name:HEINZE, KATHLEEN A (MS,RD,LDN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:HEINZE
Suffix:
Gender:F
Credentials:MS,RD,LDN
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,RD,LDN
Mailing Address - Street 1:60 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:GOREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62939-3106
Mailing Address - Country:US
Mailing Address - Phone:618-889-7607
Mailing Address - Fax:
Practice Address - Street 1:60 EAGLE DR
Practice Address - Street 2:
Practice Address - City:GOREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62939-3106
Practice Address - Country:US
Practice Address - Phone:618-889-7607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003017133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered