Provider Demographics
NPI:1033748033
Name:KIMBERLY, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:KIMBERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6169 CHADDERTON CIR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4483
Mailing Address - Country:US
Mailing Address - Phone:304-550-1994
Mailing Address - Fax:
Practice Address - Street 1:6169 CHADDERTON CIR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4483
Practice Address - Country:US
Practice Address - Phone:304-550-1994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered