Provider Demographics
NPI:1750959300
Name:WIEMANN, KIMBERLEY BROOKE (MS, RD, CDN)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:BROOKE
Last Name:WIEMANN
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MELLOW LN
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-6325
Mailing Address - Country:US
Mailing Address - Phone:631-921-2851
Mailing Address - Fax:
Practice Address - Street 1:12 MELLOW LN
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-6325
Practice Address - Country:US
Practice Address - Phone:631-921-2851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2022-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1012200133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered