Provider Demographics
NPI:1639315948
Name:WASHBURN, KIMBERLY ANN (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:WASHBURN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1311A N MILDRED RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2231
Mailing Address - Country:US
Mailing Address - Phone:970-565-8556
Mailing Address - Fax:970-564-1134
Practice Address - Street 1:1311A N MILDRED RD
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2231
Practice Address - Country:US
Practice Address - Phone:970-565-8556
Practice Address - Fax:970-564-1134
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZJOH104338485207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ379623Medicaid