Provider Demographics
NPI:1609291194
Name:KIMBERLAIN, AMY (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:KIMBERLAIN
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:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-204-4203
Mailing Address - Fax:
Practice Address - Street 1:13101 S DIXIE HWY STE 420
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-6530
Practice Address - Country:US
Practice Address - Phone:786-204-4203
Practice Address - Fax:786-576-0404
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4575133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered