Healthcare Provider Details

I. General information

NPI: 1477264026
Provider Name (Legal Business Name): KIMBERLY ANN SHEA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY ANN WALLACE

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 DOOLITTLE DR
ELLSWORTH AFB SD
57706-4821
US

IV. Provider business mailing address

2900 DOOLITTLE DR
ELLSWORTH AFB SD
57706-4821
US

V. Phone/Fax

Practice location:
  • Phone: 605-385-3111
  • Fax: 605-385-3620
Mailing address:
  • Phone: 605-385-3111
  • Fax: 605-385-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: