Basic Information
| Provider Information | |||||||||
| NPI: | 1073692307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRSKY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MS RD LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST WOT 12TH FL | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088526175 | ||||||||
| FaxNumber: | 5085952941 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 PLANTATION STREET | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088526175 | ||||||||
| FaxNumber: | 5085952941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 02/18/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 364 | MA | Y | Dietary & Nutritional Service Providers | Nutritionist |
No ID Information.