Provider Demographics
NPI:1417263765
Name:ANDERSON, KIMBERLEE MARIE (RD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4967 BENTGRASS RUN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6127
Mailing Address - Country:US
Mailing Address - Phone:706-248-0890
Mailing Address - Fax:
Practice Address - Street 1:4967 BENTGRASS RUN DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-6127
Practice Address - Country:US
Practice Address - Phone:706-248-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002758133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered