Provider Demographics
NPI:1649514217
Name:ILES, KIMBERLY (RD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ILES
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8300 HEALTH PARK
Mailing Address - Street 2:STE 325
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4730
Mailing Address - Country:US
Mailing Address - Phone:919-870-1001
Mailing Address - Fax:919-516-0673
Practice Address - Street 1:8300 HEALTH PARK
Practice Address - Street 2:STE 325
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-4730
Practice Address - Country:US
Practice Address - Phone:919-870-1001
Practice Address - Fax:919-516-0673
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCR1067307133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered