Provider Demographics
NPI:1972922458
Name:KING NELSON WEDERQUIST, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KING NELSON WEDERQUIST
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 1:417 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-2503
Mailing Address - Country:US
Mailing Address - Phone:515-408-7353
Mailing Address - Fax:
Practice Address - Street 1:417 10TH AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-2503
Practice Address - Country:US
Practice Address - Phone:515-408-7353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096865163W00000X, 163WC0400X, 163WD0400X, 163WH0200X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WW0000XNursing Service ProvidersRegistered NurseWound Care