Basic Information
| Provider Information | |||||||||
| NPI: | 1316128192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERREJON | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, RD, LDN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPRENGELMEYER | ||||||||
| OtherFirstName: | KATRINA | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MS, RD, LDN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | EVANSTON HOSPITAL | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701206 | ||||||||
| FaxNumber: | 8475701248 | ||||||||
| Practice Location | |||||||||
| Address1: | 9977 WOODS DR | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600771057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476638540 | ||||||||
| FaxNumber: | 8476631015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2007 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 164-004790 | IL | Y | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
ID Information
| ID | Type | State | Issuer | Description | 164-004790 | 01 | IL | IL STATE LIC | OTHER |