Healthcare Provider Details

I. General information

NPI: 1568384576
Provider Name (Legal Business Name): KIMBERLY ANN CHURCHILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16154 MAIN AVE SE # 134
PRIOR LAKE MN
55372-4800
US

IV. Provider business mailing address

16209 EVANSTON AVE SE
PRIOR LAKE MN
55372-2596
US

V. Phone/Fax

Practice location:
  • Phone: 952-447-3000
  • Fax:
Mailing address:
  • Phone: 612-209-2796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13830
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: