Healthcare Provider Details

I. General information

NPI: 1235522574
Provider Name (Legal Business Name): KIMBERLY EMMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 12/10/2025
Certification Date:
Deactivation Date: 11/14/2023
Reactivation Date: 12/10/2025

III. Provider practice location address

129 EDEN VALLEY RD
ROSBURG WA
98643-9637
US

IV. Provider business mailing address

129 EDEN VALLEY RD
ROSBURG WA
98643-9637
US

V. Phone/Fax

Practice location:
  • Phone: 347-901-0574
  • Fax: 360-465-2680
Mailing address:
  • Phone: 347-901-0574
  • Fax: 360-465-2680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI00001781
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: