Provider Demographics
NPI:1760985865
Name:GILLILAND, KIM NAN (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:NAN
Last Name:GILLILAND
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 S GRAND CANYON DR APT 2084
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-7120
Mailing Address - Country:US
Mailing Address - Phone:847-254-0397
Mailing Address - Fax:
Practice Address - Street 1:2651 PASEO VERDE PKWY STE 180
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-6616
Practice Address - Country:US
Practice Address - Phone:702-616-4901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV39273-DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered