Healthcare Provider Details

I. General information

NPI: 1467704213
Provider Name (Legal Business Name): KIMBERLEE G CARRANZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 BRIGGS ST SUITE 990
SAN ANTONIO TX
78224-1286
US

IV. Provider business mailing address

5316 TRAIL LAKE DR
FORT WORTH TX
76133-1931
US

V. Phone/Fax

Practice location:
  • Phone: 210-226-9536
  • Fax: 817-789-6849
Mailing address:
  • Phone: 817-292-8787
  • Fax: 817-789-6849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDT06282
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: