Provider Demographics
NPI:1679308225
Name:CHANDLER, KIMBERLY M (MSH, RD, LD/N)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:MSH, RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 MAJESTIC EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0611
Mailing Address - Country:US
Mailing Address - Phone:904-553-1179
Mailing Address - Fax:
Practice Address - Street 1:632 MAJESTIC EAGLE DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-0611
Practice Address - Country:US
Practice Address - Phone:904-553-1179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4882133N00000X
FL963168133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionist