Healthcare Provider Details

I. General information

NPI: 1194185009
Provider Name (Legal Business Name): KIMBERLY HAINES CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 E SIOUX AVE
PIERRE SD
57501-3300
US

IV. Provider business mailing address

1610 SKERROLS ST APT E1
FORT PIERRE SD
57532-2359
US

V. Phone/Fax

Practice location:
  • Phone: 605-945-5560
  • Fax:
Mailing address:
  • Phone: 605-770-4571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP001044
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: