Provider Demographics
NPI:1053847467
Name:GLENN, KIMBERLY SIMKIN (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SIMKIN
Last Name:GLENN
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 LAKE SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1975
Mailing Address - Country:US
Mailing Address - Phone:678-557-1306
Mailing Address - Fax:
Practice Address - Street 1:820 LAKE SUMMIT DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1975
Practice Address - Country:US
Practice Address - Phone:678-557-1306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2094133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered