Healthcare Provider Details

I. General information

NPI: 1508307703
Provider Name (Legal Business Name): KIMBERLY CHAMBERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 14TH AVE
LONGVIEW WA
98632-2316
US

IV. Provider business mailing address

921 14TH AVENUE
LONGVIEW WA
98632
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-0203
  • Fax: 360-577-0269
Mailing address:
  • Phone: 360-423-0203
  • Fax: 360-577-0269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number60555197
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number60220195
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: