Healthcare Provider Details

I. General information

NPI: 1700768736
Provider Name (Legal Business Name): AUBREY KNICKERBOCKER MS RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8348 DITTMER RIDGE RD
DITTMER MO
63023-1110
US

IV. Provider business mailing address

8348 DITTMER RIDGE RD
DITTMER MO
63023-1110
US

V. Phone/Fax

Practice location:
  • Phone: 704-301-2400
  • Fax:
Mailing address:
  • Phone: 704-301-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86325936
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: