Provider Demographics
NPI:1609110212
Name:MATHIS, KIMBERLY MARIE (LAC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 S POWER RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85209
Mailing Address - Country:US
Mailing Address - Phone:480-985-7070
Mailing Address - Fax:
Practice Address - Street 1:2509 S POWER RD
Practice Address - Street 2:SUITE 115
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-6695
Practice Address - Country:US
Practice Address - Phone:480-985-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0854171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist