Provider Demographics
NPI:1932868643
Name:KIRK, DEBRA JOY (RD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JOY
Last Name:KIRK
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 1:35 WALNUT GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:RISING SUN
Mailing Address - State:MD
Mailing Address - Zip Code:21911-1775
Mailing Address - Country:US
Mailing Address - Phone:410-441-9156
Mailing Address - Fax:
Practice Address - Street 1:1700 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7529
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003394133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered