Provider Demographics
NPI:1922463637
Name:FIFE, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:FIFE
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 1:365 RIVER PL
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-9058
Mailing Address - Country:US
Mailing Address - Phone:616-340-1974
Mailing Address - Fax:
Practice Address - Street 1:11652 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-8465
Practice Address - Country:US
Practice Address - Phone:616-248-5147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703114708164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse