Provider Demographics
NPI:1740353143
Name:BROOKS, KIMBRA MICHELLE (MS, RD, LD, CDE)
Entity type:Individual
Prefix:MRS
First Name:KIMBRA
Middle Name:MICHELLE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MS, RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72104-2179
Mailing Address - Country:US
Mailing Address - Phone:501-337-2689
Mailing Address - Fax:
Practice Address - Street 1:500 S UNIVERSITY AVE STE 615
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5308
Practice Address - Country:US
Practice Address - Phone:501-666-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR652133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W989Medicare ID - Type Unspecified