Provider Demographics
NPI:1033153788
Name:RILEY, KIMBERLY SAMANTHA (RD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SAMANTHA
Last Name:RILEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6146 100TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-4557
Mailing Address - Country:US
Mailing Address - Phone:551-265-8405
Mailing Address - Fax:
Practice Address - Street 1:6146 100TH AVE E
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-4557
Practice Address - Country:US
Practice Address - Phone:551-265-8405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5730133V00000X
FLND 5730133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered