Healthcare Provider Details

I. General information

NPI: 1366742306
Provider Name (Legal Business Name): KAITLYN KIMBALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E 21ST ST
CLOVIS NM
88101-3703
US

IV. Provider business mailing address

700 E 21ST ST
CLOVIS NM
88101-3703
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-3851
  • Fax:
Mailing address:
  • Phone: 575-762-3851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number49317
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: