Provider Demographics
NPI:1992768428
Name:WIMBERLY, KELLI A (RD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:A
Last Name:WIMBERLY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:J
Other - Last Name:ABBOUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1701 21ST ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8941
Mailing Address - Country:US
Mailing Address - Phone:337-479-6056
Mailing Address - Fax:
Practice Address - Street 1:524 S RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5725
Practice Address - Country:US
Practice Address - Phone:337-430-5448
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1717133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H635CR91Medicare ID - Type Unspecified