Provider Demographics
NPI:1730839812
Name:KIDWELL, DESTINY (RD)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:KIDWELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 E US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IN
Mailing Address - Zip Code:47558-5318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3131 TAMARACK CT APT 1008
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8004
Practice Address - Country:US
Practice Address - Phone:812-486-9323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003390A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty