Provider Demographics
NPI:1700768736
Name:KNICKERBOCKER, AUBREY (MS RDN)
Entity type:Individual
Prefix:
First Name:AUBREY
Middle Name:
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:MS RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8348 DITTMER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DITTMER
Mailing Address - State:MO
Mailing Address - Zip Code:63023-1110
Mailing Address - Country:US
Mailing Address - Phone:704-301-2400
Mailing Address - Fax:
Practice Address - Street 1:8348 DITTMER RIDGE RD
Practice Address - Street 2:
Practice Address - City:DITTMER
Practice Address - State:MO
Practice Address - Zip Code:63023-1110
Practice Address - Country:US
Practice Address - Phone:704-301-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-22
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86325936133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered