=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356125546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIM HEATH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2023
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4140 MCKNIGHT RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-0921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-498-6767
-----------------------------------------------------
Fax | 479-968-1673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 TRAILS END
-----------------------------------------------------
City | WASKOM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75692-5642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 902-926-9647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 1134762
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------