Healthcare Provider Details

I. General information

NPI: 1104579069
Provider Name (Legal Business Name): KIMBERLEY MAE WILSON RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1933 HAVILAND DR
VIRGINIA BEACH VA
23454-6704
US

IV. Provider business mailing address

1933 HAVILAND DR
VIRGINIA BEACH VA
23454-6704
US

V. Phone/Fax

Practice location:
  • Phone: 302-465-3066
  • Fax:
Mailing address:
  • Phone: 302-465-3066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number86100729
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number86100729
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86100729
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: