Basic Information
| Provider Information | |||||||||
| NPI: | 1871588814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEDDEN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MNT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NUNN | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | JUNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2900 16TH ST | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474213510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122751200 | ||||||||
| FaxNumber: | 8122751370 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 16TH ST | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474213510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122751200 | ||||||||
| FaxNumber: | 8122751370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 05/18/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 132700000X | 37000507A | IN | Y | Dietary & Nutritional Service Providers | Dietary Manager |
No ID Information.