Healthcare Provider Details

I. General information

NPI: 1588808505
Provider Name (Legal Business Name): MRS. KIMBERLY DOMMERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 GREMILLION CRICLE
IOTA LA
70543-3250
US

IV. Provider business mailing address

PO BOX 218
IOTA LA
70543-0218
US

V. Phone/Fax

Practice location:
  • Phone: 337-824-6250
  • Fax: 337-821-9306
Mailing address:
  • Phone: 337-824-6250
  • Fax: 337-821-9306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1718
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: