Provider Demographics
NPI:1891355624
Name:CUNNINGHAM, KRISTIN AMY (RD)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:AMY
Last Name:CUNNINGHAM
Suffix:
Gender:
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:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-747-2066
Mailing Address - Fax:314-747-7111
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV IM GASTROENTEROLOGY, STE 12B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-747-2066
Practice Address - Fax:314-747-7111
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008029877133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO350077348Medicaid