Provider Demographics
NPI:1942647789
Name:PROCTOR, KIMBERLY LYNN (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4035 MOUNT VERNON RD SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-3801
Mailing Address - Country:US
Mailing Address - Phone:319-365-4623
Mailing Address - Fax:
Practice Address - Street 1:4035 MOUNT VERNON RD SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-3801
Practice Address - Country:US
Practice Address - Phone:319-365-4623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01478133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered