1447602743 NPI number — MS. KIMBERLY KAY ANDERSON LISW

Table of content: MS. KIMBERLY KAY ANDERSON LISW (NPI 1447602743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447602743 NPI number — MS. KIMBERLY KAY ANDERSON LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
KIMBERLY
Provider Middle Name:
KAY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LISW
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:
1447602743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
761 CAMP CARDINAL BLVD
Provider Second Line Business Mailing Address:
BOX 2271
Provider Business Mailing Address City Name:
CORALVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-594-8010
Provider Business Mailing Address Fax Number:
319-356-2587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2421 CORAL COURT
Provider Second Line Business Practice Location Address:
SUITE #129
Provider Business Practice Location Address City Name:
CORALVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-322-8887
Provider Business Practice Location Address Fax Number:
319-356-2587
Provider Enumeration Date:
07/11/2016

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: 104100000X , with the licence number:  05940 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 05940 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0409321 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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