Provider Demographics
NPI:1659590768
Name:FUTRAL, KIMANDRIA
Entity Type:Individual
Prefix:MRS
First Name:KIMANDRIA
Middle Name:
Last Name:FUTRAL
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 1:133 WOODBURY PARK PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8191
Mailing Address - Country:US
Mailing Address - Phone:601-605-4878
Mailing Address - Fax:
Practice Address - Street 1:1929 SPILLWAY RD STE A
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6079
Practice Address - Country:US
Practice Address - Phone:601-992-5370
Practice Address - Fax:601-992-5370
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS1040235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09625729Medicaid