Provider Demographics
NPI:1871559104
Name:DWYER, KRISTIN R (RD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:R
Last Name:DWYER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:R
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1133 SHOREWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-3786
Mailing Address - Country:US
Mailing Address - Phone:630-682-8556
Mailing Address - Fax:
Practice Address - Street 1:1325 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1449
Practice Address - Country:US
Practice Address - Phone:630-801-5899
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK04848Medicare ID - Type Unspecified