Healthcare Provider Details

I. General information

NPI: 1023970829
Provider Name (Legal Business Name): KIMBERLY COOK BOEHM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8941 BALDWIN RD
BALDWIN IL
62217-1607
US

IV. Provider business mailing address

8941 BALDWIN RD
BALDWIN IL
62217-1607
US

V. Phone/Fax

Practice location:
  • Phone: 618-606-0493
  • Fax:
Mailing address:
  • Phone: 618-606-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.008217
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: