1740911924 NPI number — MS. KIMBERLY ANNE PROVOST BCABA

Table of content: MS. KIMBERLY ANNE PROVOST BCABA (NPI 1740911924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740911924 NPI number — MS. KIMBERLY ANNE PROVOST BCABA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROVOST
Provider First Name:
KIMBERLY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BCABA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PROVOST
Provider Other First Name:
KIM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1740911924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 ALLEN BROOK LN STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495-9211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-876-7111
Provider Business Mailing Address Fax Number:
802-448-6905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
147 ALLEN BROOK LN STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05495-9211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-876-7111
Provider Business Practice Location Address Fax Number:
802-448-6905
Provider Enumeration Date:
06/20/2022

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: 106E00000X , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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