=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912540725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY ANN JUDY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2019
-----------------------------------------------------
Last Update Date | 10/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 PIN OAK LN
-----------------------------------------------------
City | KEYSER
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26726-5908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-597-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1326
-----------------------------------------------------
City | KEYSER
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26726-1326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 1258
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------