Provider Demographics
NPI:1104391424
Name:SCHMIDT, KIMBERLY JO (RDN, LD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JO
Last Name:SCHMIDT
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JO
Other - Last Name:ADOLFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13486 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-9414
Mailing Address - Country:US
Mailing Address - Phone:208-484-7770
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6270
Practice Address - Country:US
Practice Address - Phone:208-484-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-13
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-522133VN1004X, 133VN1005X, 133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic