Provider Demographics
NPI:1972688489
Name:DIXON, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DIXON
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 1:19490 SANDRIDGE WAY STE 170
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3467
Mailing Address - Country:US
Mailing Address - Phone:703-723-4088
Mailing Address - Fax:703-723-4564
Practice Address - Street 1:19490 SANDRIDGE WAY STE 170
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-3467
Practice Address - Country:US
Practice Address - Phone:703-478-0190
Practice Address - Fax:703-471-0247
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006074174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA496628Medicare ID - Type Unspecified