Provider Demographics
NPI:1063906329
Name:KERN, NICOLE SUZANNE (RD, LDN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUZANNE
Last Name:KERN
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 42ND AVENUE DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6893
Mailing Address - Country:US
Mailing Address - Phone:309-757-1085
Mailing Address - Fax:
Practice Address - Street 1:750 42ND AVENUE DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6893
Practice Address - Country:US
Practice Address - Phone:309-757-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091659133V00000X
IL164.007411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered