Provider Demographics
NPI:1912624297
Name:HORSTMANN, KIP (MS, LIC NUTRITIONIS)
Entity Type:Individual
Prefix:
First Name:KIP
Middle Name:
Last Name:HORSTMANN
Suffix:
Gender:M
Credentials:MS, LIC NUTRITIONIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 EMILY CT
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-2455
Mailing Address - Country:US
Mailing Address - Phone:502-210-1785
Mailing Address - Fax:
Practice Address - Street 1:620 BIRDIE BANNISTER ROAD
Practice Address - Street 2:
Practice Address - City:EDDYVILLE
Practice Address - State:KY
Practice Address - Zip Code:42038
Practice Address - Country:US
Practice Address - Phone:502-444-5025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY275500133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist