Healthcare Provider Details

I. General information

NPI: 1790742559
Provider Name (Legal Business Name): KIMBERLY STILLMAN RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUHL REGIONAL MEDICAL CENTER NUTRITION CARE DIVISION
APO AE
09180
DE

IV. Provider business mailing address

LANDSTUHL REGIONAL MEDICAL CENTER ATTM: MCEUL-DCCS (CREDENTIALS), CMR 402
APO AE
09180
DE

V. Phone/Fax

Practice location:
  • Phone: 011496371867144
  • Fax:
Mailing address:
  • Phone: 011496371868839
  • Fax: 011496371866133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002995
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: