Provider Demographics
NPI:1568028355
Name:RICHARDSON, KIMBERLY DAWN (LPN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9213 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-1317
Mailing Address - Country:US
Mailing Address - Phone:405-264-7627
Mailing Address - Fax:405-455-3342
Practice Address - Street 1:9213 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-1317
Practice Address - Country:US
Practice Address - Phone:405-264-7627
Practice Address - Fax:405-455-3342
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58407164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK463977830OtherADULT DAY HEALTH CENTER