Provider Demographics
NPI:1093214207
Name:KIMUHU, TERESIA (LPN)
Entity Type:Individual
Prefix:
First Name:TERESIA
Middle Name:
Last Name:KIMUHU
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 CAMBRIDGE SQ STE C
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1071 CAMBRIDGE SQ STE C
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1843
Practice Address - Country:US
Practice Address - Phone:770-609-6781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-03
Last Update Date:2018-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN080153164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPN080153OtherLPN LICENSE