1508559964 NPI number — KIMBERLY NICOLE STA ANA HENSON PT

Table of content: KIMBERLY NICOLE STA ANA HENSON PT (NPI 1508559964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508559964 NPI number — KIMBERLY NICOLE STA ANA HENSON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENSON
Provider First Name:
KIMBERLY NICOLE
Provider Middle Name:
STA ANA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1508559964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 N OAK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PERRYVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63775-2733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-768-5958
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1609 N PRINCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101-4850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-935-0360
Provider Business Practice Location Address Fax Number:
575-935-0361
Provider Enumeration Date:
05/31/2023

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:  6123 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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