Provider Demographics
NPI:1538985270
Name:WALCK, KIMBERLY W (RDN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:W
Last Name:WALCK
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 SAVAGE FAMILY LN
Mailing Address - Street 2:
Mailing Address - City:TEACHEY
Mailing Address - State:NC
Mailing Address - Zip Code:28464-5600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:147 SAVAGE FAMILY LN
Practice Address - Street 2:
Practice Address - City:TEACHEY
Practice Address - State:NC
Practice Address - Zip Code:28464-5600
Practice Address - Country:US
Practice Address - Phone:910-284-9957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered