Healthcare Provider Details

I. General information

NPI: 1083069090
Provider Name (Legal Business Name): KIMBERLY EMMICK RDN, CD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

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:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberDI00001781
License Number StateWA

VIII. Authorized Official

Name: KIMBERLY EMMICK
Title or Position: REGISTERED DIETITIAN NUTRITIONIST
Credential: RDN, CD
Phone: 347-901-0574