Provider Demographics
NPI:1215778444
Name:ELLIS, KIMBERLY M (MS, MPH, RD, LD/N)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS, MPH, 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 1:10257 SW VILLAGE PWKY APT 202
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10257 SW VILLAGE PKWY APT 202
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2367
Practice Address - Country:US
Practice Address - Phone:863-697-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6277133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered