Provider Demographics
NPI:1316373665
Name:DRAKES, KIMBERLY O (LNM)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:O
Last Name:DRAKES
Suffix:
Gender:F
Credentials:LNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 WEST ST
Mailing Address - Street 2:BLDG 2
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-6006
Mailing Address - Country:US
Mailing Address - Phone:860-276-6800
Mailing Address - Fax:
Practice Address - Street 1:1131 WEST ST
Practice Address - Street 2:BLDG 2
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-6006
Practice Address - Country:US
Practice Address - Phone:860-276-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000285367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
000285OtherLICENSE