Provider Demographics
NPI:1932100294
Name:ROGERS, KIMBERLY KAY (RD LD N)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:ROGERS
Suffix:
Gender:F
Credentials:RD LD N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34945-4125
Mailing Address - Country:US
Mailing Address - Phone:772-461-1349
Mailing Address - Fax:
Practice Address - Street 1:290 SUNRISE DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34945-4125
Practice Address - Country:US
Practice Address - Phone:772-461-1349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 1278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLD # ND1278OtherLICENSED
FLRD 713403OtherREGISTRATION