Healthcare Provider Details

I. General information

NPI: 1285132043
Provider Name (Legal Business Name): KIMBERLY LYLES CORMIER RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 AMBASSADOR CAFFERY PKWY STE 408
LAFAYETTE LA
70508-6950
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-3980
  • Fax: 337-470-3989
Mailing address:
  • Phone: 225-526-0002
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2220
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: