Provider Demographics
NPI:1053084145
Name:HUSTAD, KIMBERLY ANN
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:HUSTAD
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 1:2107 19TH AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-6508
Mailing Address - Country:US
Mailing Address - Phone:701-609-6066
Mailing Address - Fax:
Practice Address - Street 1:2107 19TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-6508
Practice Address - Country:US
Practice Address - Phone:701-609-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant