Healthcare Provider Details

I. General information

NPI: 1720171069
Provider Name (Legal Business Name): KIMBERLY SHARRELL COORE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS NASSAU LHA 4
FPO UNITED STATES
AE
US

IV. Provider business mailing address

539 DEER NECK DR
CHESAPEAKE VA
23323-7101
US

V. Phone/Fax

Practice location:
  • Phone: 757-434-4864
  • Fax:
Mailing address:
  • Phone: 757-753-2444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7481
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: