Provider Demographics
NPI:1386214484
Name:DRAKE, KIMBERLY
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 516
Mailing Address - Street 2:
Mailing Address - City:SHAW
Mailing Address - State:MS
Mailing Address - Zip Code:38773
Mailing Address - Country:US
Mailing Address - Phone:662-719-8467
Mailing Address - Fax:
Practice Address - Street 1:500 CAANAN STREET
Practice Address - Street 2:
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38773
Practice Address - Country:US
Practice Address - Phone:662-719-8467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251S00000XAgenciesCommunity/Behavioral Health