Healthcare Provider Details

I. General information

NPI: 1740252485
Provider Name (Legal Business Name): KIMBERLY LYNN BAKER AT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 OLD VIRGINIA RD
POCOMOKE CITY MD
21851-3049
US

IV. Provider business mailing address

3705 VILLAGE TRL
SNOW HILL MD
21863-3062
US

V. Phone/Fax

Practice location:
  • Phone: 443-614-4183
  • Fax:
Mailing address:
  • Phone: 443-614-4183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0000005
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: