MEDICARE: KIMBERLY JO CALLOW RDN, IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	86115695	AZ
2	174N00000X	Lactation Consultant (Non-RN)	L-163757	AZ

General Provider Information

NPI Number	:	1770201931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY JO CALLOW RDN, IBCLC

Provider Business Mailing Address
First Line	:	3203 W GOLDMINE MOUNTAIN CV
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85144-3063
Country	:	US
Telephone Number	:	480-232-0246
Fax Number	:

Provider Business Practice Location Address
First Line	:	3203 W GOLDMINE MOUNTAIN CV
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85144-3063
Country	:	US
Telephone Number	:	480-232-0246
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2022
Last Update Date	:	03/03/2026

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