Provider Demographics
NPI:1871720615
Name:KUMKE, NICOLE (RDN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KUMKE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:PEFLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:761 45TH ST STE 110
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2899
Practice Address - Country:US
Practice Address - Phone:219-922-3020
Practice Address - Fax:219-922-3023
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003576A133V00000X
IL164.004214133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered