Provider Demographics
NPI:1982030102
Name:WELLS, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:KAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1610 E. SUNSHINE STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-619-1827
Mailing Address - Fax:
Practice Address - Street 1:1610 E. SUNSHINE STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-523-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MO2013029481235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist