Provider Demographics
NPI:1477018430
Name:DAVID, KIM (RD)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:DAVID
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 1:13 BUDS TRL
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3162
Mailing Address - Country:US
Mailing Address - Phone:508-868-7805
Mailing Address - Fax:
Practice Address - Street 1:13 BUDS TRL
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:ME
Practice Address - Zip Code:04021-3162
Practice Address - Country:US
Practice Address - Phone:508-868-7805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1436133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered