Healthcare Provider Details

I. General information

NPI: 1265734032
Provider Name (Legal Business Name): KIMBERLY A MCCLAIN 311760-31
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 OWEN AVE
RACINE WI
53403-2145
US

IV. Provider business mailing address

1504 OWEN AVE
RACINE WI
53403-2145
US

V. Phone/Fax

Practice location:
  • Phone: 262-412-4301
  • Fax:
Mailing address:
  • Phone: 262-412-4301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number311760-31
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: