Provider Demographics
NPI:1609107705
Name:THOMAS, KIMBERLY R
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:THOMAS
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 1:2606 E EDGERTON AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-1890
Mailing Address - Country:US
Mailing Address - Phone:414-855-4677
Mailing Address - Fax:
Practice Address - Street 1:2606 E EDGERTON AVE STE 108
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-1890
Practice Address - Country:US
Practice Address - Phone:414-855-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker