Provider Demographics
NPI:1740450410
Name:KILPATRICK, KIMBERLY RACHELLE (RD, LD)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:RACHELLE
Last Name:KILPATRICK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 SOUTHCREST PKWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-4739
Mailing Address - Country:US
Mailing Address - Phone:662-772-3199
Mailing Address - Fax:
Practice Address - Street 1:7601 SOUTHCREST PKWY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4739
Practice Address - Country:US
Practice Address - Phone:662-772-3199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-09
Last Update Date:2008-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1029133V00000X
TNLDN0000001901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered