Provider Demographics
NPI:1871024232
Name:MAITLAND, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MAITLAND
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 1:20920 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MC KENNEY
Mailing Address - State:VA
Mailing Address - Zip Code:23872-2516
Mailing Address - Country:US
Mailing Address - Phone:804-586-7113
Mailing Address - Fax:804-375-1019
Practice Address - Street 1:20920 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MC KENNEY
Practice Address - State:VA
Practice Address - Zip Code:23872-2516
Practice Address - Country:US
Practice Address - Phone:804-586-7113
Practice Address - Fax:804-375-1019
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0169542849251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0169542849Medicaid