Healthcare Provider Details

I. General information

NPI: 1366914368
Provider Name (Legal Business Name): KIMBERLY REPASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 DARES BEACH RD
PRINCE FREDERICK MD
20678-4208
US

IV. Provider business mailing address

342 ENGLISH OAK LN
PRINCE FREDERICK MD
20678-6121
US

V. Phone/Fax

Practice location:
  • Phone: 443-550-8345
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number16778
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: