Healthcare Provider Details

I. General information

NPI: 1962928747
Provider Name (Legal Business Name): KIMBERLY KUCZYNSKI MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 EDGEMEADE RD
UPPER MARLBORO MD
20772-8088
US

IV. Provider business mailing address

7106 LADYSLIPPER LN
UPPER MARLBORO MD
20772-6328
US

V. Phone/Fax

Practice location:
  • Phone: 215-964-1657
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD02227
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: