Provider Demographics
NPI:1437754090
Name:LABRECQUE, KIMBERLY ANN (RD, CDN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:LABRECQUE
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:385 WATERVLIET SHAKER RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-4741
Mailing Address - Country:US
Mailing Address - Phone:518-213-7526
Mailing Address - Fax:
Practice Address - Street 1:385 WATERVLIET SHAKER RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4741
Practice Address - Country:US
Practice Address - Phone:518-213-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86035013133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered