Provider Demographics
NPI:1891051140
Name:KIM, ANNIE LEE (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:LEE
Last Name:KIM
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26074 LUGO DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6507
Mailing Address - Country:US
Mailing Address - Phone:909-631-7447
Mailing Address - Fax:
Practice Address - Street 1:26074 LUGO DR
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-6507
Practice Address - Country:US
Practice Address - Phone:909-631-7447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1039779133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered