Provider Demographics
NPI:1528179504
Name:SAMUELSON VISHER, KIMBERLY COURTNEY (RD)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:COURTNEY
Last Name:SAMUELSON VISHER
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 1:1400 E EL PASO AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2637
Mailing Address - Country:US
Mailing Address - Phone:559-999-1378
Mailing Address - Fax:
Practice Address - Street 1:7300 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2941
Practice Address - Country:US
Practice Address - Phone:559-448-5118
Practice Address - Fax:559-448-5460
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA875187133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA875187OtherCDR