Provider Demographics
NPI:1700381134
Name:WILCOX, KIMBERLY LEINANI (RDN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LEINANI
Last Name:WILCOX
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 SLEEPING LADY LN
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-2419
Mailing Address - Country:US
Mailing Address - Phone:907-306-7324
Mailing Address - Fax:
Practice Address - Street 1:621 W DIMOND BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1704
Practice Address - Country:US
Practice Address - Phone:907-644-8733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK130620133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered