Provider Demographics
NPI:1295398568
Name:SMITH, KIMBERLY JOAN (MS)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JOAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:JOAN
Other - Last Name:VISSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:2415 32ND ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7813
Mailing Address - Country:US
Mailing Address - Phone:651-356-2493
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-5799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1706235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist