Provider Demographics
NPI:1477264026
Name:SHEA, KIMBERLY ANN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:SHEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KLIMBERLY
Other - Middle Name:ANN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 DOOLITTLE DR
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-4821
Mailing Address - Country:US
Mailing Address - Phone:605-385-3111
Mailing Address - Fax:605-385-3620
Practice Address - Street 1:2900 DOOLITTLE DR
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4821
Practice Address - Country:US
Practice Address - Phone:605-385-3111
Practice Address - Fax:605-385-3620
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No171000000XOther Service ProvidersMilitary Health Care Provider