Provider Demographics
NPI:1144342965
Name:HUMPHREY, LINDA (MS, RD, CD, CDE)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MS, RD, CD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47750-0001
Mailing Address - Country:US
Mailing Address - Phone:812-485-1814
Mailing Address - Fax:812-485-1804
Practice Address - Street 1:901 ST MARY S DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47750-0001
Practice Address - Country:US
Practice Address - Phone:812-485-1814
Practice Address - Fax:812-485-1804
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
813164133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN940280D6Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER