=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083857841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARISSA SUZANNE HERNDON R.D., L.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2009
-----------------------------------------------------
Last Update Date | 04/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 CLUB VILLAGE DR SUITE 101
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-447-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6025 S HIGHWAY KK
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-9475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-424-8064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 2009005906
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------