Provider Demographics
NPI:1255569760
Name:SPILLER, KIMBERLY LOVELL
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:LOVELL
Last Name:SPILLER
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 1:1212 S LILLY ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-5310
Mailing Address - Country:US
Mailing Address - Phone:870-763-9226
Mailing Address - Fax:
Practice Address - Street 1:1510 BYRUM RD
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-8033
Practice Address - Country:US
Practice Address - Phone:870-532-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161010724Medicaid