1659596450 NPI number — KIMBERLY A HAVINS PMHNP-RN-FNP-C

Table of content: KIMBERLY A HAVINS PMHNP-RN-FNP-C (NPI 1659596450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659596450 NPI number — KIMBERLY A HAVINS PMHNP-RN-FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAVINS
Provider First Name:
KIMBERLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-RN-FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OTTO
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659596450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1714 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA FALLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76301-5011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-766-4482
Provider Business Mailing Address Fax Number:
940-766-4487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1714 10TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA FALLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76301-5011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-766-4482
Provider Business Practice Location Address Fax Number:
940-766-4487
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  617471 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0367754-22 . This is a "NP CERTIFICATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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