Healthcare Provider Details

I. General information

NPI: 1912740846
Provider Name (Legal Business Name): VICTORIA CHOUKLINA RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E NIFONG BLVD
COLUMBIA MO
65201-3708
US

IV. Provider business mailing address

1208 GRACE LN
BOONVILLE MO
65233-2143
US

V. Phone/Fax

Practice location:
  • Phone: 573-442-8595
  • Fax:
Mailing address:
  • Phone: 314-971-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1042045
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: