Provider Demographics
NPI:1063257061
Name:CASEY, KIM (RD, LD/N)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:CASEY
Suffix:
Gender:F
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 NW 49TH LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4337
Mailing Address - Country:US
Mailing Address - Phone:954-593-9015
Mailing Address - Fax:
Practice Address - Street 1:2423 NW 49TH LN
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-4337
Practice Address - Country:US
Practice Address - Phone:954-593-9015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12988133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered