Provider Demographics
NPI:1689002123
Name:HAWKINS-PANKRATZ, KIMBERLY JANE (LADC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JANE
Last Name:HAWKINS-PANKRATZ
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26864 NORWAY LN
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-2356
Mailing Address - Country:US
Mailing Address - Phone:218-330-0785
Mailing Address - Fax:
Practice Address - Street 1:13021 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-7439
Practice Address - Country:US
Practice Address - Phone:218-829-9307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303572101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)