Provider Demographics
NPI:1982399812
Name:KOGER, MAKENNA AUTUMN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MAKENNA
Middle Name:AUTUMN
Last Name:KOGER
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W CHICAGO AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5711
Mailing Address - Country:US
Mailing Address - Phone:248-930-9246
Mailing Address - Fax:
Practice Address - Street 1:1111 W CHICAGO AVE APT 2A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5711
Practice Address - Country:US
Practice Address - Phone:248-930-9246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008541133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered