Healthcare Provider Details

I. General information

NPI: 1972588341
Provider Name (Legal Business Name): KIMBERLY J. KENGOR MS, RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 SAHARA TRL
YOUNGSTOWN OH
44514-3667
US

IV. Provider business mailing address

PO BOX 11230
YOUNGSTOWN OH
44511-0230
US

V. Phone/Fax

Practice location:
  • Phone: 330-506-2336
  • Fax: 330-270-5773
Mailing address:
  • Phone: 330-506-2336
  • Fax: 330-270-5733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number419
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: