Provider Demographics
NPI:1285027672
Name:BRANT, KIMBERLEE (LPN LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:
Last Name:BRANT
Suffix:
Gender:F
Credentials:LPN LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5538 S ADONIS PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-6950
Mailing Address - Country:US
Mailing Address - Phone:208-890-1109
Mailing Address - Fax:
Practice Address - Street 1:5460 W FRANKLIN RD STE H
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1080
Practice Address - Country:US
Practice Address - Phone:208-890-1109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-287172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker