Provider Demographics
NPI:1629613989
Name:LANDSBERG, KIMBERLY ANNE (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:LANDSBERG
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:BLOOMFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1488 N SUNUP WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7023
Mailing Address - Country:US
Mailing Address - Phone:208-559-8319
Mailing Address - Fax:
Practice Address - Street 1:1488 N SUNUP WAY
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7023
Practice Address - Country:US
Practice Address - Phone:208-559-8319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA809925133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA809925OtherACADEMY OF NUTRITION AND DIETETICS
IDD-659OtherIDAHO BOARD OF MEDICINE