Provider Demographics
NPI:1134392350
Name:CRIST, KIMBERLY KAE (LPN)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAE
Last Name:CRIST
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34666 ROCK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621-4214
Mailing Address - Country:US
Mailing Address - Phone:218-694-3049
Mailing Address - Fax:218-785-2707
Practice Address - Street 1:28647 HWY 92
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621
Practice Address - Country:US
Practice Address - Phone:218-694-3049
Practice Address - Fax:218-785-2707
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0006952-14675177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging