Provider Demographics
NPI:1003308487
Name:NISHIYAMA, KIMBERLY (DTR)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:NISHIYAMA
Suffix:
Gender:F
Credentials:DTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20325 N 51ST AVE STE 166
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20325 N 51ST AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5674
Practice Address - Country:US
Practice Address - Phone:602-341-5248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86092429136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered