Provider Demographics
NPI:1194054098
Name:BLAIR, KIMBERLY (RD, CD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5640 SAINT CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47620-8324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-2438
Practice Address - Country:US
Practice Address - Phone:800-772-8740
Practice Address - Fax:812-465-6238
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-24
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN844425133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered