Provider Demographics
NPI:1972588341
Name:KENGOR, KIMBERLY J (MS, RD, CDE)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:KENGOR
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11230
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-0230
Mailing Address - Country:US
Mailing Address - Phone:330-506-2336
Mailing Address - Fax:330-270-5733
Practice Address - Street 1:900 SAHARA TRL
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-3667
Practice Address - Country:US
Practice Address - Phone:330-506-2336
Practice Address - Fax:330-270-5773
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH419133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000003266560OtherANTHEM DIABETES EDUCATOR
OH721593OtherAETNA, DIETITIAN
OHKEM02381Medicare ID - Type UnspecifiedSPEC 71