Provider Demographics
NPI:1114362308
Name:DICKSON, KIMBERLY K (RD, CDE)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:DICKSON
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 I-30
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6905
Mailing Address - Country:US
Mailing Address - Phone:469-800-2800
Mailing Address - Fax:469-800-2801
Practice Address - Street 1:1575 I-30
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6905
Practice Address - Country:US
Practice Address - Phone:469-800-2800
Practice Address - Fax:469-800-2801
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06169133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX289403YKY6Medicare PIN