Provider Demographics
NPI:1083003123
Name:STORM, KIMBERLY (MS, RD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:STORM
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 QUAIL MDWS
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92603-4236
Mailing Address - Country:US
Mailing Address - Phone:408-679-3638
Mailing Address - Fax:
Practice Address - Street 1:1601 AVOCADO AVE STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7798
Practice Address - Country:US
Practice Address - Phone:949-719-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1062796133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered