Provider Demographics
NPI:1508313586
Name:BEAN, KIMBERLI LANELLE
Entity Type:Individual
Prefix:
First Name:KIMBERLI
Middle Name:LANELLE
Last Name:BEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KIMBERLI
Other - Middle Name:LANELLE
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 HAMILTON STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501
Mailing Address - Country:US
Mailing Address - Phone:541-690-7475
Mailing Address - Fax:
Practice Address - Street 1:140 SOUTH HOLLY STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-774-8201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator