Healthcare Provider Details

I. General information

NPI: 1699368787
Provider Name (Legal Business Name): KATHERINE A INGLE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: N/A N/A N/A

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 02/19/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 SOUTH WOOD STREET PEDIATRIC GENETICS 12TH FLOOR M/C 856
CHICAGO IL
60612
US

IV. Provider business mailing address

840 SOUTH WOOD STREET PEDIATRIC GENETICS 12TH FLOOR M/C 856
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-9283
  • Fax: 312-355-0739
Mailing address:
  • Phone: 312-996-9283
  • Fax: 312-355-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164.006904
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: