Provider Demographics
NPI:1639487333
Name:DEVOU, KIM G (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:G
Last Name:DEVOU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 N DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-9401
Mailing Address - Country:US
Mailing Address - Phone:575-762-4455
Mailing Address - Fax:575-935-5455
Practice Address - Street 1:2301 N MLK BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-9401
Practice Address - Country:US
Practice Address - Phone:575-762-4455
Practice Address - Fax:575-935-5455
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01670363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39778088Medicaid