Provider Demographics
NPI:1578979761
Name:BACKUS, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BACKUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 N PERSHING DR
Mailing Address - Street 2:APT 516
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-1446
Mailing Address - Country:US
Mailing Address - Phone:315-527-0734
Mailing Address - Fax:
Practice Address - Street 1:1201 S HAYES ST
Practice Address - Street 2:CVS MINUTE CLINIC
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-2700
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338782-1363LF0000X
VA0024172839363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily