Provider Demographics
NPI:1003419847
Name:KING, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KING
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:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:ND
Mailing Address - Zip Code:58346-0052
Mailing Address - Country:US
Mailing Address - Phone:701-351-3850
Mailing Address - Fax:
Practice Address - Street 1:240 THIRD AVENUE SE
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:ND
Practice Address - Zip Code:58346
Practice Address - Country:US
Practice Address - Phone:701-351-3850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant