Provider Demographics
NPI:1164693164
Name:PAINE, KIMBERLY JANE (MED, CCS)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JANE
Last Name:PAINE
Suffix:
Gender:F
Credentials:MED, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2070 OLD BRIDGE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2495
Mailing Address - Country:US
Mailing Address - Phone:703-499-8787
Mailing Address - Fax:703-499-8282
Practice Address - Street 1:2070 OLD BRIDGE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2495
Practice Address - Country:US
Practice Address - Phone:703-499-8787
Practice Address - Fax:703-499-8282
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201000309231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist