Provider Demographics
NPI:1417288713
Name:POPE, KIMBERLY DIANE (BHRS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:POPE
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:HARTSHORNE
Mailing Address - State:OK
Mailing Address - Zip Code:74547-3627
Mailing Address - Country:US
Mailing Address - Phone:918-429-2851
Mailing Address - Fax:
Practice Address - Street 1:729 LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:HARTSHORNE
Practice Address - State:OK
Practice Address - Zip Code:74547-3627
Practice Address - Country:US
Practice Address - Phone:918-429-2851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746580AMedicaid