Provider Demographics
NPI:1265976849
Name:ELLIOTT, KIMBERLY (RDN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 TATE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7787 RICHMOND HWY
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522-8680
Practice Address - Country:US
Practice Address - Phone:434-290-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-15
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86056561133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered