Provider Demographics
NPI:1093972341
Name:AN, KIMBERLY ANNE (AUD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:AN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9055 SPRINGBROOK DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5841
Mailing Address - Country:US
Mailing Address - Phone:763-780-9155
Mailing Address - Fax:763-236-1312
Practice Address - Street 1:9055 SPRINGBROOK DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5841
Practice Address - Country:US
Practice Address - Phone:763-236-1312
Practice Address - Fax:763-236-1312
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9327231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA513910013Medicare PIN