Provider Demographics
NPI:1770703365
Name:BOOMER, KAREN (RD LD CDE)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:BOOMER
Suffix:
Gender:F
Credentials:RD LD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-3400
Mailing Address - Fax:502-588-3401
Practice Address - Street 1:601 S FLOYD ST
Practice Address - Street 2:STE 403
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1837
Practice Address - Country:US
Practice Address - Phone:502-588-3400
Practice Address - Fax:502-588-3401
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYK0440133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP400028987Medicare PIN