Healthcare Provider Details

I. General information

NPI: 1639508260
Provider Name (Legal Business Name): KIM WARNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 VIA MONTICANO
HENDERSON NV
89052-1502
US

IV. Provider business mailing address

1113 VIA MONTICANO
HENDERSON NV
89052-1502
US

V. Phone/Fax

Practice location:
  • Phone: 904-699-0032
  • Fax:
Mailing address:
  • Phone: 904-699-0032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: