Provider Demographics
NPI:1003374430
Name:MATTHEWS, KIMBERLY EVETT
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:EVETT
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8527
Mailing Address - Country:US
Mailing Address - Phone:318-343-8744
Mailing Address - Fax:318-345-7123
Practice Address - Street 1:645 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8527
Practice Address - Country:US
Practice Address - Phone:318-343-8744
Practice Address - Fax:318-345-7123
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1972980514Medicaid