Healthcare Provider Details

I. General information

NPI: 1316789472
Provider Name (Legal Business Name): KIMBERLY MICHELLE CONCRA LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 ROUTE 134 BUILDING 1-4
SOUTH DENNIS MA
02660
US

IV. Provider business mailing address

11 SHEFFIELD RD
BREWSTER MA
02631-2847
US

V. Phone/Fax

Practice location:
  • Phone: 508-258-5923
  • Fax: 855-710-7222
Mailing address:
  • Phone: 508-237-6616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number887
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number887
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number887
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: