1558589911 NPI number — LISA TARTAMELLA KIMMEL MS, RD, CD-N

Table of content: LISA TARTAMELLA KIMMEL MS, RD, CD-N (NPI 1558589911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558589911 NPI number — LISA TARTAMELLA KIMMEL MS, RD, CD-N

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TARTAMELLA KIMMEL
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RD, CD-N
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558589911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 CENTENNIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06461-1678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-878-6493
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 YORK ST
Provider Second Line Business Practice Location Address:
NUTRITION CLINIC- CBB52
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06510-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-688-2264
Provider Business Practice Location Address Fax Number:
203-688-2141
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  000101 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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