Provider Demographics
NPI:1972220440
Name:VANTELLMAN, KIMBERLY KAREN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAREN
Last Name:VANTELLMAN
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 1:1204 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424-2418
Mailing Address - Country:US
Mailing Address - Phone:660-868-1950
Mailing Address - Fax:
Practice Address - Street 1:1204 S 15TH ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-2418
Practice Address - Country:US
Practice Address - Phone:660-868-1950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver