Provider Demographics
NPI:1225531734
Name:EVANS, KIMBERLY (MAT 15556)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:MAT 15556
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9026
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96745-9026
Mailing Address - Country:US
Mailing Address - Phone:808-960-2097
Mailing Address - Fax:
Practice Address - Street 1:75-5597 PALANI RD STE B-1
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1661
Practice Address - Country:US
Practice Address - Phone:808-327-9791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-10
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15556225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist