Provider Demographics
NPI:1770479412
Name:ANDERSON, KIMBERLY DEANNA NICOLE
Entity type:Individual
Prefix:
First Name:KIMBERLY DEANNA
Middle Name:NICOLE
Last Name:ANDERSON
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 1:105 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-9444
Mailing Address - Country:US
Mailing Address - Phone:318-230-5215
Mailing Address - Fax:
Practice Address - Street 1:2924 KNIGHT ST STE 369
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2413
Practice Address - Country:US
Practice Address - Phone:318-210-0587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator