Provider Demographics
NPI:1972070167
Name:PREVOST, KIMBERLY T
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:T
Last Name:PREVOST
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 1:25226 JUSTICE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIDING
Mailing Address - State:VA
Mailing Address - Zip Code:20152-6011
Mailing Address - Country:US
Mailing Address - Phone:703-861-7660
Mailing Address - Fax:
Practice Address - Street 1:24440 STONE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20166-2247
Practice Address - Country:US
Practice Address - Phone:703-861-7660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001222497163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant