Individual
MRS. KIMBERLY M OTTER
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
RD LDN
Contact information
Practice address
935 JERSEY ST, QUINCY, IL 62301-4030
(217) 228-2413
(217) 228-2416
Mailing address
935 JERSEY ST, QUINCY, IL 62301-4030
(217) 228-2413
(217) 228-2416
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
2004029302
MO
133V00000X
Registered Dietitian
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000009329891
PRIVATE HEALTHCARE SYSTEM
IL
01
—
00132009
BLUE CROSS BLUE SHIELD
IL
01
—
075113
QUINCY HEALTH CARE MGMT.
IL
Enumeration date
08/12/2005
Last updated
07/08/2007
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