Provider Demographics
NPI:1962072934
Name:WEAVER, KATHERINE (RD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:WEAVER
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 1:7411 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1876
Mailing Address - Country:US
Mailing Address - Phone:708-763-6398
Mailing Address - Fax:
Practice Address - Street 1:7411 LAKE ST STE 2100
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1897
Practice Address - Country:US
Practice Address - Phone:708-763-6398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007459133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered