Provider Demographics
NPI:1396490942
Name:KULTGEN, OLIVIA ANN (RD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ANN
Last Name:KULTGEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 14-200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5966
Mailing Address - Country:US
Mailing Address - Phone:312-695-7382
Mailing Address - Fax:312-695-0014
Practice Address - Street 1:675 N SAINT CLAIR ST STE 14-200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5966
Practice Address - Country:US
Practice Address - Phone:312-695-7382
Practice Address - Fax:312-695-0014
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-12
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008590133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered