Healthcare Provider Details

I. General information

NPI: 1275204547
Provider Name (Legal Business Name): MICHELLE KUIMBA RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2021
Last Update Date: 09/25/2021
Certification Date: 09/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1734 MARYLAND AVE STE 200
BALTIMORE MD
21201-5804
US

IV. Provider business mailing address

3925 BEECH AVE APT 421
BALTIMORE MD
21211-2262
US

V. Phone/Fax

Practice location:
  • Phone: 240-722-1014
  • Fax:
Mailing address:
  • Phone: 202-470-8276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX5028
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI100001197
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: