Provider Demographics
NPI:1568140564
Name:BOULOS, KIMBERLY ALEXIS (NC LMT #20552)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ALEXIS
Last Name:BOULOS
Suffix:
Gender:F
Credentials:NC LMT #20552
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:304 CHESTNUT PKWY APT 8227
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-3862
Mailing Address - Country:US
Mailing Address - Phone:551-253-7256
Mailing Address - Fax:
Practice Address - Street 1:304 CHESTNUT PKWY APT 8227
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-3862
Practice Address - Country:US
Practice Address - Phone:551-253-7256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No374J00000XNursing Service Related ProvidersDoula