Provider Demographics
NPI:1770719916
Name:WIEDMAN, KIMBERLY M (RD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:WIEDMAN
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 9825
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-8825
Mailing Address - Country:US
Mailing Address - Phone:360-397-8473
Mailing Address - Fax:360-397-8110
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD
Practice Address - Street 2:BUILDING 17
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:360-397-8473
Practice Address - Fax:360-397-8110
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered