Provider Demographics
NPI:1790360485
Name:BENNETT, KIMBERLEY (NUTRITIONIST)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:MISS
Other - First Name:KIMBERLEY
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NUTRITIONIST
Mailing Address - Street 1:1260 COLLEGE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-2700
Mailing Address - Country:US
Mailing Address - Phone:336-818-0733
Mailing Address - Fax:
Practice Address - Street 1:1260 COLLEGE AVE STE 1
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-2700
Practice Address - Country:US
Practice Address - Phone:336-818-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-14
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist