Healthcare Provider Details

I. General information

NPI: 1679308225
Provider Name (Legal Business Name): KIMBERLY M CHANDLER MSH, RD, LD/N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 MAJESTIC EAGLE DR
PONTE VEDRA FL
32081-0611
US

IV. Provider business mailing address

632 MAJESTIC EAGLE DR
PONTE VEDRA FL
32081-0611
US

V. Phone/Fax

Practice location:
  • Phone: 904-553-1179
  • Fax:
Mailing address:
  • Phone: 904-553-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND4882
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number963168
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: