Provider Demographics
NPI:1790956852
Name:HAGENBUCH, KIMBERLY M (MS, RD, LDN, CDCES)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:HAGENBUCH
Suffix:
Gender:F
Credentials:MS, RD, LDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 LOG POND DR
Mailing Address - Street 2:
Mailing Address - City:HORSHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19044-1978
Mailing Address - Country:US
Mailing Address - Phone:215-813-5702
Mailing Address - Fax:
Practice Address - Street 1:183 LOG POND DR
Practice Address - Street 2:
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-1978
Practice Address - Country:US
Practice Address - Phone:215-813-5702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003575133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered