Provider Demographics
NPI:1457568925
Name:SCHOENACKER, KHIMBERLY ROSE (RD, CSP, LD)
Entity Type:Individual
Prefix:MRS
First Name:KHIMBERLY
Middle Name:ROSE
Last Name:SCHOENACKER
Suffix:
Gender:F
Credentials:RD, CSP, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3098
Mailing Address - Country:US
Mailing Address - Phone:503-418-5257
Mailing Address - Fax:503-418-5317
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-418-5257
Practice Address - Fax:503-418-5317
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA957173OtherADA REGISTRATION NUMBER