Provider Demographics
NPI:1629453709
Name:HERSEY, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HERSEY
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 1:1075 JONES STREET
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857
Mailing Address - Country:US
Mailing Address - Phone:573-888-5925
Mailing Address - Fax:
Practice Address - Street 1:1075 JONES ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3866
Practice Address - Country:US
Practice Address - Phone:573-888-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0Medicaid