Provider Demographics
NPI:1912096892
Name:GRAVLEY, KIMBERLY FAYE (RD,LD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:FAYE
Last Name:GRAVLEY
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 1:13302 TUCKER LAKE DR.
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-4552
Mailing Address - Country:US
Mailing Address - Phone:502-710-1058
Mailing Address - Fax:502-267-9694
Practice Address - Street 1:13302 TUCKER LAKE DR.
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-4552
Practice Address - Country:US
Practice Address - Phone:502-710-1058
Practice Address - Fax:502-267-9694
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY - 1367133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01938OtherNUMBER FOR CBIS BILLING