MEDICARE: DEBORAH KIMBLE LD CDE MSPH CPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	ND1612	FL

General Provider Information

NPI Number	:	1760600290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH KIMBLE LD CDE MSPH CPT

Provider Business Mailing Address
First Line	:	4851 LAKE SHORE DR
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772-7577
Country	:	US
Telephone Number	:	407-973-0037
Fax Number	:	407-957-1186

Provider Business Practice Location Address
First Line	:	4851 LAKE SHORE DR
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772-7577
Country	:	US
Telephone Number	:	407-973-0037
Fax Number	:	407-957-1186

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2007
Last Update Date	:	07/08/2007

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