Provider Demographics
NPI:1639886245
Name:KIMMERLY, BREANNA ALICE
Entity Type:Individual
Prefix:MISS
First Name:BREANNA
Middle Name:ALICE
Last Name:KIMMERLY
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 1:7849 HIGHWAY 57
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:ND
Mailing Address - Zip Code:58370-9000
Mailing Address - Country:US
Mailing Address - Phone:701-381-0137
Mailing Address - Fax:
Practice Address - Street 1:7849 HIGHWAY 57
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:ND
Practice Address - Zip Code:58370-9000
Practice Address - Country:US
Practice Address - Phone:701-381-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant