Provider Demographics
NPI:1871588814
Name:LEDDEN, KIMBERLY J (MNT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:LEDDEN
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JUNE
Other - Last Name:NUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-3510
Mailing Address - Country:US
Mailing Address - Phone:812-275-1200
Mailing Address - Fax:812-275-1370
Practice Address - Street 1:2900 16TH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3510
Practice Address - Country:US
Practice Address - Phone:812-275-1200
Practice Address - Fax:812-275-1370
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000507A132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ50106Medicare UPIN
IN940070E4Medicare ID - Type Unspecified