Healthcare Provider Details

I. General information

NPI: 1316488950
Provider Name (Legal Business Name): KIMBERLY COLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE
JACKSON MI
49202-2179
US

IV. Provider business mailing address

1200 N WEST AVE
JACKSON MI
49202-2179
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number470420799
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: