Healthcare Provider Details

I. General information

NPI: 1366276859
Provider Name (Legal Business Name): KIMBERLY V MARES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3549 STATE HIGHWAY 518
HOLMAN NM
87723-2006
US

IV. Provider business mailing address

10 RANGER RD
MORA NM
87732-2340
US

V. Phone/Fax

Practice location:
  • Phone: 575-387-3217
  • Fax:
Mailing address:
  • Phone: 575-387-3217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN-84829
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: