1619265477 NPI number — KIMBERLEE JOANNA HUDGINS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619265477 NPI number — KIMBERLEE JOANNA HUDGINS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUDGINS
Provider First Name:
KIMBERLEE
Provider Middle Name:
JOANNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1619265477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6204 HILLSIDE RD
Provider Second Line Business Mailing Address:
SUITE 1000
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79109-7196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-355-7633
Provider Business Mailing Address Fax Number:
806-355-7644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6204 HILLSIDE RD
Provider Second Line Business Practice Location Address:
SUITE 1000
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79109-7196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-355-7633
Provider Business Practice Location Address Fax Number:
806-355-7644
Provider Enumeration Date:
07/14/2011

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:  1208809 , 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: 149984001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 207164901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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