Provider Demographics
NPI:1942617311
Name:FAIRCHILD, KERRY (RD,LD,IBCLC)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:RD,LD,IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 NORWICH DR
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-4245
Mailing Address - Country:US
Mailing Address - Phone:440-590-1883
Mailing Address - Fax:
Practice Address - Street 1:506 NORWICH DR
Practice Address - Street 2:
Practice Address - City:BROADVIEW HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44147-4245
Practice Address - Country:US
Practice Address - Phone:440-590-1883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD4826133V00000X
OH11212511174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN