Provider Demographics
NPI:1407243686
Name:SPEROS, KIMBERLY (RD CNSC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SPEROS
Suffix:
Gender:F
Credentials:RD CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 E NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4217
Mailing Address - Country:US
Mailing Address - Phone:602-677-4164
Mailing Address - Fax:602-532-7146
Practice Address - Street 1:350 W THOMAS RD
Practice Address - Street 2:FOOD & NUTRITION DEPARTMENT
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4409
Practice Address - Country:US
Practice Address - Phone:602-406-3115
Practice Address - Fax:602-406-6660
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11002133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered