Provider Demographics
NPI:1083069090
Name:KIMBERLY EMMICK RDN, CD
Entity Type:Organization
Organization Name:KIMBERLY EMMICK RDN, CD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:EMMICK
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CD
Authorized Official - Phone:347-901-0574
Mailing Address - Street 1:129 EDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ROSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98643-9637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:129 EDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:ROSBURG
Practice Address - State:WA
Practice Address - Zip Code:98643-9637
Practice Address - Country:US
Practice Address - Phone:347-901-0574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001781261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service