Provider Demographics
NPI:1992381792
Name:BENJAMIN, KIMBERLY STALLWORTH
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:STALLWORTH
Last Name:BENJAMIN
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 1:6729 OVERVIEW LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7628
Mailing Address - Country:US
Mailing Address - Phone:334-235-5295
Mailing Address - Fax:
Practice Address - Street 1:6729 OVERVIEW LN
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7628
Practice Address - Country:US
Practice Address - Phone:334-235-5295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care