Provider Demographics
NPI:1780142489
Name:WALTER, KIRBY (RD, CLC)
Entity type:Individual
Prefix:
First Name:KIRBY
Middle Name:
Last Name:WALTER
Suffix:
Gender:F
Credentials:RD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3817 N CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4102
Mailing Address - Country:US
Mailing Address - Phone:312-502-3345
Mailing Address - Fax:
Practice Address - Street 1:3817 N CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4102
Practice Address - Country:US
Practice Address - Phone:312-502-3345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X
IL86017636133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL86017636OtherREGISTERED DIETITIAN LICENSE