1255777975 NPI number — MISS KIMBERLY DAWN LISTER M.ED., QP

Table of content: MISS KIMBERLY DAWN LISTER M.ED., QP (NPI 1255777975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255777975 NPI number — MISS KIMBERLY DAWN LISTER M.ED., QP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LISTER
Provider First Name:
KIMBERLY
Provider Middle Name:
DAWN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.ED., QP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255777975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3518 CHISTOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTHEWS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28105-1944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-299-9265
Provider Business Mailing Address Fax Number:
704-357-7921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2815 COLISEUM CENTRE DR
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28217-1452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-357-7932
Provider Business Practice Location Address Fax Number:
704-357-7921
Provider Enumeration Date:
05/21/2013

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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