Provider Demographics
NPI:1568631794
Name:WILLARD, KIMBERLY (MS RD LD)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-2331
Mailing Address - Country:US
Mailing Address - Phone:800-358-8262
Mailing Address - Fax:740-593-3743
Practice Address - Street 1:510 W UNION ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2331
Practice Address - Country:US
Practice Address - Phone:800-358-8262
Practice Address - Fax:740-593-3743
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6370133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered