1063608321 NPI number — MRS. KIMBERLY SUE DENHAM MPT

Table of content: MRS. KIMBERLY SUE DENHAM MPT (NPI 1063608321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063608321 NPI number — MRS. KIMBERLY SUE DENHAM MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENHAM
Provider First Name:
KIMBERLY
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DORSEY
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063608321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1326 CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZACHARY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70791-2743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-654-8208
Provider Business Mailing Address Fax Number:
225-654-4642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1326 CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZACHARY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70791-2743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-654-8208
Provider Business Practice Location Address Fax Number:
225-654-4642
Provider Enumeration Date:
09/20/2007

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: 225100000X , with the licence number:  10203R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT0006420 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10203R . This is a "PT LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".