Provider Demographics
NPI:1700197092
Name:KIM, SARA NICOLETTI (MA, RD)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:NICOLETTI
Last Name:KIM
Suffix:
Gender:F
Credentials:MA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 PEACH AVE APT 67
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5728
Mailing Address - Country:US
Mailing Address - Phone:484-467-6864
Mailing Address - Fax:
Practice Address - Street 1:989 PEACH AVE APT 67
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5728
Practice Address - Country:US
Practice Address - Phone:484-467-6864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA965012133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered