Healthcare Provider Details

I. General information

NPI: 1982909800
Provider Name (Legal Business Name): KIMALISA KAY SHAMBLIN BA, RT(R)(CT), RVT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 DIVISION ST
SOUTH CHARLESTON WV
25309-1469
US

IV. Provider business mailing address

374 WILDLIFE WAY
CLENDENIN WV
25045-5193
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-9617
  • Fax:
Mailing address:
  • Phone: 304-206-1420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number1540
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number1540
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number1540
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number1540
License Number StateWV
# 5
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number1540
License Number StateWV
# 6
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number1540
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: