Provider Demographics
NPI:1255477428
Name:KIMPSTON, SUSAN ELAINE (DIETITIAN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELAINE
Last Name:KIMPSTON
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1422
Mailing Address - Street 2:
Mailing Address - City:HELENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:92342-1422
Mailing Address - Country:US
Mailing Address - Phone:760-952-2532
Mailing Address - Fax:760-952-2532
Practice Address - Street 1:14938 TOURNAMENT DR
Practice Address - Street 2:
Practice Address - City:HELENDALE
Practice Address - State:CA
Practice Address - Zip Code:92342-1422
Practice Address - Country:US
Practice Address - Phone:760-952-2532
Practice Address - Fax:760-952-2532
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA866288133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered