Provider Demographics
NPI:1952643637
Name:THEDFORD, KIMBERLY E (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:THEDFORD
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 E 47TH ST
Mailing Address - Street 2:2W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3600
Mailing Address - Country:US
Mailing Address - Phone:773-315-7133
Mailing Address - Fax:
Practice Address - Street 1:1034 E 47TH ST
Practice Address - Street 2:2W
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3600
Practice Address - Country:US
Practice Address - Phone:773-315-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164-001611133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered