Provider Demographics
NPI:1316789472
Name:CONCRA, KIMBERLY MICHELLE (LDN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:CONCRA
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SHEFFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631-2847
Mailing Address - Country:US
Mailing Address - Phone:508-237-6616
Mailing Address - Fax:
Practice Address - Street 1:902 ROUTE 134
Practice Address - Street 2:BUILDING 1-4
Practice Address - City:SOUTH DENNIS
Practice Address - State:MA
Practice Address - Zip Code:02660
Practice Address - Country:US
Practice Address - Phone:508-258-5923
Practice Address - Fax:855-710-7222
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA887133NN1002X, 133V00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered