1942748736 NPI number — KIMBERLY CROCKETT BRASURE NP-C

Table of content: KIMBERLY CROCKETT BRASURE NP-C (NPI 1942748736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942748736 NPI number — KIMBERLY CROCKETT BRASURE NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRASURE
Provider First Name:
KIMBERLY
Provider Middle Name:
CROCKETT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
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:
1942748736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31707 BRASURE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAGSBORO
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19939-4172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-278-0093
Provider Business Mailing Address Fax Number:
302-278-0096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35998 ZION CHURCH RD UNIT 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19945-4501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-278-0093
Provider Business Practice Location Address Fax Number:
302-278-0096
Provider Enumeration Date:
02/01/2017

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: 363L00000X , with the licence number:  LG0001010 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com