Provider Demographics
NPI:1073225462
Name:SHIMP, KATRINA M (RDH, OMT)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:M
Last Name:SHIMP
Suffix:
Gender:F
Credentials:RDH, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PIEDMONT ST #632
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-3869
Mailing Address - Country:US
Mailing Address - Phone:336-496-1636
Mailing Address - Fax:
Practice Address - Street 1:201 PIEDMONT ST #632
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-3869
Practice Address - Country:US
Practice Address - Phone:717-639-8996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12153124Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12153OtherSPECIALIST
NC12153OtherREGISTERED DENTAL HYGIENIST OF NORTH CAROLINA