Healthcare Provider Details

I. General information

NPI: 1144881855
Provider Name (Legal Business Name): KRISTEN KIMBLE MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N FAIRBANKS CT STE 7-121
CHICAGO IL
60611-3013
US

IV. Provider business mailing address

710 N FAIRBANKS CT STE 7-121
CHICAGO IL
60611-3013
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-7437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164007690
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: