Provider Demographics
NPI:1114249117
Name:WALLACE, KIMBERLY (LRN)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 US HIGHWAY 61 NORTH
Mailing Address - Street 2:
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851
Mailing Address - Country:US
Mailing Address - Phone:573-359-2600
Mailing Address - Fax:573-359-1103
Practice Address - Street 1:925 HIGHWAY V V
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857
Practice Address - Country:US
Practice Address - Phone:573-888-5925
Practice Address - Fax:573-888-9365
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007032845163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse