Provider Demographics
NPI:1073732400
Name:ANDERSON, KIMBERLY SUE (CNA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SUE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 AVE. B
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501
Mailing Address - Country:US
Mailing Address - Phone:515-576-6308
Mailing Address - Fax:
Practice Address - Street 1:1140 AVENUE B
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-4586
Practice Address - Country:US
Practice Address - Phone:515-576-6308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07397483747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0739748Medicaid