Provider Demographics
NPI:1912558974
Name:DOLL, KIMBERLY MARIE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:DOLL
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 1:604 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:HENNING
Mailing Address - State:MN
Mailing Address - Zip Code:56551-4108
Mailing Address - Country:US
Mailing Address - Phone:218-548-7501
Mailing Address - Fax:
Practice Address - Street 1:604 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:HENNING
Practice Address - State:MN
Practice Address - Zip Code:56551-4108
Practice Address - Country:US
Practice Address - Phone:218-548-7501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-21
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1100666253J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No253J00000XAgenciesFoster Care Agency