Provider Demographics
NPI:1891197711
Name:WALLANDER, KIMBERLY G (RD)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:G
Last Name:WALLANDER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:450 VETERANS MEMORIAL PKWY STE 8C
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-5300
Mailing Address - Country:US
Mailing Address - Phone:401-396-9331
Mailing Address - Fax:401-396-9369
Practice Address - Street 1:450 VETERANS MEMORIAL PKWY STE 8C
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5300
Practice Address - Country:US
Practice Address - Phone:401-396-9331
Practice Address - Fax:401-396-9369
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN00797133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered