Provider Demographics
NPI:1265982151
Name:SELF, KIMSEY (MNT)
Entity type:Individual
Prefix:
First Name:KIMSEY
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2259 S JOSEPHINE ST
Mailing Address - Street 2:#303
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-4846
Mailing Address - Country:US
Mailing Address - Phone:512-970-3532
Mailing Address - Fax:
Practice Address - Street 1:2259 S JOSEPHINE ST
Practice Address - Street 2:#303
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-4846
Practice Address - Country:US
Practice Address - Phone:512-970-3532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education