Provider Demographics
NPI:1578686093
Name:MANZO, KIMBERLY ILEN (MS, RD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ILEN
Last Name:MANZO
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COOPER LN
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-2151
Mailing Address - Country:US
Mailing Address - Phone:908-766-7185
Mailing Address - Fax:
Practice Address - Street 1:147 COLUMBIA TPKE
Practice Address - Street 2:SUITE 301
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-2113
Practice Address - Country:US
Practice Address - Phone:973-410-0452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ919989133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered