Provider Demographics
NPI:1093086084
Name:COPELAND, KIMBERLY DAWN
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:COPELAND
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 1:16226 W BURCHETT RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-0366
Mailing Address - Country:US
Mailing Address - Phone:918-456-5374
Mailing Address - Fax:
Practice Address - Street 1:16226 W BURCHETT RD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0366
Practice Address - Country:US
Practice Address - Phone:918-456-5374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor