Provider Demographics
NPI:1851373021
Name:WALDENMAIER, KIM (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:WALDENMAIER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 678207
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8207
Mailing Address - Country:US
Mailing Address - Phone:800-841-4236
Mailing Address - Fax:706-653-1162
Practice Address - Street 1:101 E WOOD ST STE 330
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6522
Practice Address - Fax:888-972-8644
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2669363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003918Medicaid
SCNP0915Medicaid
SCNP0915Medicaid
SCAA10141324Medicare PIN
SCP00432773Medicare PIN
SCAA10147895Medicare PIN