Provider Demographics
NPI:1134419062
Name:MONROE, KIMERLI ANN (R D, LD)
Entity type:Individual
Prefix:
First Name:KIMERLI
Middle Name:ANN
Last Name:MONROE
Suffix:
Gender:F
Credentials:R D, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-0007
Mailing Address - Country:US
Mailing Address - Phone:409-384-6718
Mailing Address - Fax:409-384-6529
Practice Address - Street 1:797 W GIBSON ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4973
Practice Address - Country:US
Practice Address - Phone:409-384-5713
Practice Address - Fax:409-384-6529
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02513133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered