Provider Demographics
NPI:1023741113
Name:CRUZ, KIMBERLY S (LD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:CRUZ
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:S
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19289C SAINT JOSEPH ST
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-9248
Mailing Address - Country:US
Mailing Address - Phone:228-831-8764
Mailing Address - Fax:
Practice Address - Street 1:19289C SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-9248
Practice Address - Country:US
Practice Address - Phone:228-831-8764
Practice Address - Fax:228-233-1252
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD2281133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered