Provider Demographics
NPI:1003220344
Name:BANDELIER, KIMBERLEY (RD, LD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:BANDELIER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8115 TAHOE PARKE CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-4056
Mailing Address - Country:US
Mailing Address - Phone:512-786-7858
Mailing Address - Fax:
Practice Address - Street 1:3724 JEFFERSON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6225
Practice Address - Country:US
Practice Address - Phone:512-693-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-15
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81859133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered