Provider Demographics
NPI:1669871224
Name:LANCE, KIMBERLEY (MS, RD, CD)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:LANCE
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-5709
Mailing Address - Country:US
Mailing Address - Phone:812-237-2172
Mailing Address - Fax:812-242-6555
Practice Address - Street 1:3901 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5709
Practice Address - Country:US
Practice Address - Phone:812-237-2172
Practice Address - Fax:812-242-6555
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002415A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered