Healthcare Provider Details

I. General information

NPI: 1942734025
Provider Name (Legal Business Name): KIMBERLY THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 GALL STREET
LOWER BRULE SD
57548-0248
US

IV. Provider business mailing address

PO BOX 248
LOWER BRULE SD
57548-0248
US

V. Phone/Fax

Practice location:
  • Phone: 605-473-8243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0440448
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: