Provider Demographics
NPI:1447691274
Name:EDWARDS, KIMBERLY CAMILLE (RD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CAMILLE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:CAMILLE
Other - Last Name:HOUSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92531-0858
Mailing Address - Country:US
Mailing Address - Phone:951-330-4360
Mailing Address - Fax:888-978-4430
Practice Address - Street 1:3610 CENTRAL AVE
Practice Address - Street 2:STE 400
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-5907
Practice Address - Country:US
Practice Address - Phone:951-330-4360
Practice Address - Fax:888-978-4430
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA912518133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered