Provider Demographics
NPI:1447689468
Name:SPATOLA, KIMBERLY ELYSIA (RD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ELYSIA
Last Name:SPATOLA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-5043
Mailing Address - Fax:704-384-8895
Practice Address - Street 1:125 QUEENS RD STE 330
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3419
Practice Address - Country:US
Practice Address - Phone:704-384-5043
Practice Address - Fax:704-384-8895
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004277133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered