Healthcare Provider Details

I. General information

NPI: 1063284792
Provider Name (Legal Business Name): KIMBERLY RENEE AKINS-MUMPHARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 SPRINGDALE DR
BELLEVILLE IL
62223-4218
US

IV. Provider business mailing address

519 SPRINGDALE DR
BELLEVILLE IL
62223-4218
US

V. Phone/Fax

Practice location:
  • Phone: 618-623-5318
  • Fax:
Mailing address:
  • Phone: 618-623-5318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number012007514
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: