Provider Demographics
NPI:1265466593
Name:ROLIE, KIMBERLY SUE (LRD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:ROLIE
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20569 OAKDALE RD
Mailing Address - Street 2:
Mailing Address - City:UNDERWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56586-9598
Mailing Address - Country:US
Mailing Address - Phone:701-361-5970
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-239-3700
Practice Address - Fax:701-239-3705
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND409133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND409OtherSTATE LISCENSE NUMBER