Healthcare Provider Details

I. General information

NPI: 1013549088
Provider Name (Legal Business Name): KIMBERLY WASHBURN CCSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43G PINSBAARI DR
PUEBLO OF ACOMA NM
87034-1001
US

IV. Provider business mailing address

PO BOX 333
PUEBLO OF ACOMA NM
87034-0333
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5145
  • Fax: 505-552-5196
Mailing address:
  • Phone: 505-552-5145
  • Fax: 505-552-5196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: