Provider Demographics
NPI:1588019103
Name:HANSEN, KIMBERLY DEAN (AT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DEAN
Last Name:HANSEN
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 E VAUGHN AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-1015
Mailing Address - Country:US
Mailing Address - Phone:480-980-8740
Mailing Address - Fax:
Practice Address - Street 1:1302 E VAUGHN AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-1015
Practice Address - Country:US
Practice Address - Phone:480-980-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1214174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist