Provider Demographics
NPI:1760807861
Name:FLACK, KIM (MS, RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:FLACK
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WYNBROOK CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-6789
Mailing Address - Country:US
Mailing Address - Phone:615-472-8406
Mailing Address - Fax:
Practice Address - Street 1:1211 21ST AVE S
Practice Address - Street 2:607 MEDICAL ARTS BUILDING
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-1320
Practice Address - Country:US
Practice Address - Phone:615-322-0487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001997133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic