Provider Demographics
NPI:1548749203
Name:STAYTON, KIMBERLY (RN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:STAYTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6215 WAYNE WAY
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-1911
Mailing Address - Country:US
Mailing Address - Phone:314-546-5955
Mailing Address - Fax:
Practice Address - Street 1:6719 TRINITY TRAIL LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-1952
Practice Address - Country:US
Practice Address - Phone:314-546-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MO2001005289163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000000Medicaid