Provider Demographics
NPI:1104107358
Name:BIRK, LAUREN KATE (RD, LDN)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:KATE
Last Name:BIRK
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 1:203 W COLUMBIA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-8649
Mailing Address - Country:US
Mailing Address - Phone:801-717-0768
Mailing Address - Fax:
Practice Address - Street 1:812 NORTH LOGAN AVENUE
Practice Address - Street 2:PROVENA UNITED SAMARITANS MEDICAL - DIETARY DEPARTMENT
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-443-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001015297133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered