Healthcare Provider Details

I. General information

NPI: 1629266291
Provider Name (Legal Business Name): KIMBERLY SUE HANTZ R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 W. COLLEGE AVE. WEIGHT MANAGEMENT
MARQUETTE MI
49855
US

IV. Provider business mailing address

PO BOX 220
MARQUETTE MI
49855-0220
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-6955
  • Fax: 906-225-7696
Mailing address:
  • Phone: 906-225-4821
  • Fax: 906-225-4537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number689473
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: