Provider Demographics
NPI:1114485729
Name:KIMMINS, ANGELA L (IBCLC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:KIMMINS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:L
Other - Last Name:KEICHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:461 N 9TH DR
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-4562
Mailing Address - Country:US
Mailing Address - Phone:928-607-7838
Mailing Address - Fax:
Practice Address - Street 1:461 N 9TH DR
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-4562
Practice Address - Country:US
Practice Address - Phone:928-607-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN108238163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty