Provider Demographics
NPI:1629867171
Name:TADLOCK, KIMBERLY NICOLE (RDN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:TADLOCK
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:NICKI
Other - Middle Name:
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDN
Mailing Address - Street 1:532 PEEBLES AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:532 PEEBLES AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2238
Practice Address - Country:US
Practice Address - Phone:601-927-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS961860133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered