Provider Demographics
NPI:1598896649
Name:THORP, KIMBERLY SUE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:THORP
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 1:6819 ROVENNA ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-2169
Mailing Address - Country:US
Mailing Address - Phone:907-646-1412
Mailing Address - Fax:
Practice Address - Street 1:6819 ROVENNA ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-2169
Practice Address - Country:US
Practice Address - Phone:907-646-1412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK733686310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL5274Medicaid
AKHC5274Medicaid