Provider Demographics
NPI:1043886542
Name:TIMMERMAN, KIMBERLY MAE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MAE
Last Name:TIMMERMAN
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 1:237 BRANDON RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-5605
Mailing Address - Country:US
Mailing Address - Phone:864-200-5143
Mailing Address - Fax:
Practice Address - Street 1:237 BRANDON RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-5605
Practice Address - Country:US
Practice Address - Phone:864-200-5143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC293255605172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3KY3-G16-XH13Medicaid