Provider Demographics
NPI:1144495060
Name:BOMKAMP, PATRICIA A (RD,LDN)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:BOMKAMP
Suffix:
Gender:F
Credentials:RD,LDN
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:A
Other - Last Name:SHOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5510 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2381
Mailing Address - Country:US
Mailing Address - Phone:815-226-2000
Mailing Address - Fax:
Practice Address - Street 1:5510 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2381
Practice Address - Country:US
Practice Address - Phone:815-226-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001219133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered