Provider Demographics
NPI:1356601017
Name:WHELAN, KIMBERLY J (RD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:WHELAN
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:PO BOX 33093
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95031
Mailing Address - Country:US
Mailing Address - Phone:831-818-4462
Mailing Address - Fax:
Practice Address - Street 1:2211 MOORPARK AVE STE 218
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2629
Practice Address - Country:US
Practice Address - Phone:408-998-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA926569133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA926569OtherREGISTERED DIETITIAN