Provider Demographics
NPI:1609809128
Name:HATHCOCK, KIMBERLY EDITH
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:EDITH
Last Name:HATHCOCK
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 1:586 VENTURACCI LN
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-5753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5250 NEIL RD
Practice Address - Street 2:STE 207
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-6556
Practice Address - Country:US
Practice Address - Phone:775-334-4178
Practice Address - Fax:775-328-1201
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN00424363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology