Provider Demographics
NPI:1558627042
Name:MACK, KIMBERLY A (RD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:MACK
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 1:315 SKYVUE LN
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-3821
Mailing Address - Country:US
Mailing Address - Phone:847-885-0994
Mailing Address - Fax:
Practice Address - Street 1:315 SKYVUE LN
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-3821
Practice Address - Country:US
Practice Address - Phone:847-885-0994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004050133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered