Provider Demographics
NPI:1356195192
Name:CUDNIK, JUSTIN BOLES (RDN)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:BOLES
Last Name:CUDNIK
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8809 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-2022
Mailing Address - Country:US
Mailing Address - Phone:785-979-9171
Mailing Address - Fax:
Practice Address - Street 1:5500 W 123RD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-3193
Practice Address - Country:US
Practice Address - Phone:913-317-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3043133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered