Provider Demographics
NPI:1699950378
Name:AHLGRIM, ANTONIA M (RD)
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:M
Last Name:AHLGRIM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66839-2602
Mailing Address - Country:US
Mailing Address - Phone:620-364-5655
Mailing Address - Fax:
Practice Address - Street 1:801 N 4TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KS
Practice Address - Zip Code:66839-2602
Practice Address - Country:US
Practice Address - Phone:620-364-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1092133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1092OtherKS LICENSE