Healthcare Provider Details

I. General information

NPI: 1881116853
Provider Name (Legal Business Name): KIMBERLY ROSS DCN, CNS, CDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 6TH AVE W
BRADENTON FL
34205-7400
US

IV. Provider business mailing address

7026 DATE PALM LN
ELLENTON FL
34222-4316
US

V. Phone/Fax

Practice location:
  • Phone: 941-234-4541
  • Fax: 941-213-5822
Mailing address:
  • Phone: 941-234-4541
  • Fax: 941-213-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberLD.10482
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX6749
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND9114
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number164.008863
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number008524
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND9114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: