Healthcare Provider Details

I. General information

NPI: 1578189221
Provider Name (Legal Business Name): KATHLEEN COMERFORD MS, CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 12/20/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 BROAD RIPPLE AVE STE 179
INDIANAPOLIS IN
46220-2034
US

IV. Provider business mailing address

1075 BROAD RIPPLE AVE STE 179
INDIANAPOLIS IN
46220-2034
US

V. Phone/Fax

Practice location:
  • Phone: 317-934-0331
  • Fax:
Mailing address:
  • Phone: 317-934-0331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number164.007997
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: