Healthcare Provider Details

I. General information

NPI: 1235587106
Provider Name (Legal Business Name): KIMBERLEE KISTLER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6610 N LOVINGTON HWY STE 603
HOBBS NM
88240-9114
US

IV. Provider business mailing address

6610 N LOVINGTON HWY STE 603
HOBBS NM
88240-9114
US

V. Phone/Fax

Practice location:
  • Phone: 575-492-2185
  • Fax:
Mailing address:
  • Phone: 575-492-2185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number615
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: