Healthcare Provider Details

I. General information

NPI: 1518906031
Provider Name (Legal Business Name): KIMBERLEE JO NELSON RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MARSH ST
MANKATO MN
56001-4752
US

IV. Provider business mailing address

1025 MARSH ST
MANKATO MN
56001-4752
US

V. Phone/Fax

Practice location:
  • Phone: 507-625-4031
  • Fax:
Mailing address:
  • Phone: 507-625-4031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1394
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: