Basic Information
Provider Information | |||||||||
NPI: | 1669518007 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOUDERMILK-COLLINS | ||||||||
FirstName: | SHERRY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RUPARD | ||||||||
OtherFirstName: | SHERRY | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9521 NE 779 RD | ||||||||
Address2: |   | ||||||||
City: | LOWRY CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 647638179 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608907096 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1600 N 2ND ST | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MO | ||||||||
PostalCode: | 647351192 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608855511 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2001012668 | MO | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 355172107 | 05 | MO |   | MEDICAID |