Provider Demographics
NPI:1073935342
Name:KIDDLE, MARY GEORGIANA (RDN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GEORGIANA
Last Name:KIDDLE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:GEORGIANA
Other - Middle Name:
Other - Last Name:KIDDLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:147 N BRENT ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2809
Mailing Address - Country:US
Mailing Address - Phone:805-652-5066
Mailing Address - Fax:805-641-1706
Practice Address - Street 1:147 N BRENT ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2809
Practice Address - Country:US
Practice Address - Phone:805-652-5066
Practice Address - Fax:805-641-1706
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA806071133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered