Provider Demographics
NPI:1235687203
Name:BLACK, KIMBERLY (CNIM)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNIM
Mailing Address - Street 1:9811 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7528
Mailing Address - Country:US
Mailing Address - Phone:855-864-4322
Mailing Address - Fax:
Practice Address - Street 1:9811 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7528
Practice Address - Country:US
Practice Address - Phone:855-864-4322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
4054OtherABRET CNIM