Provider Demographics
NPI:1255950366
Name:HAMILTON, COLLEEN (RD LDN)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1109 W SLEEPY HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1101
Mailing Address - Country:US
Mailing Address - Phone:309-303-8077
Mailing Address - Fax:
Practice Address - Street 1:1109 W SLEEPY HOLLOW CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1101
Practice Address - Country:US
Practice Address - Phone:309-303-8077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005668133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered