Provider Demographics
NPI:1588723027
Name:THORNTON, KIM (RD,LD,CDE)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 S STATE HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4471
Mailing Address - Country:US
Mailing Address - Phone:830-997-1355
Mailing Address - Fax:830-997-1397
Practice Address - Street 1:1020 S STATE HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4471
Practice Address - Country:US
Practice Address - Phone:830-997-1355
Practice Address - Fax:830-997-1397
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT03081133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered