Provider Demographics
NPI:1164113049
Name:WILLISON, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WILLISON
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 1:25000 HAMMER TIME LN
Mailing Address - Street 2:
Mailing Address - City:FLINTSTONE
Mailing Address - State:MD
Mailing Address - Zip Code:21530-3074
Mailing Address - Country:US
Mailing Address - Phone:301-697-0564
Mailing Address - Fax:301-777-5832
Practice Address - Street 1:10102 COUNTRY CLUB RD SE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-8339
Practice Address - Country:US
Practice Address - Phone:301-777-2285
Practice Address - Fax:301-777-5832
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR200304163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse