Provider Demographics
NPI:1265946966
Name:WOODS, KIMBERLY J (PCA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:J
Last Name:WOODS
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:J
Other - Last Name:STEVEY (MAIDEN NAME)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2499 FORK RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041
Mailing Address - Country:US
Mailing Address - Phone:304-845-5893
Mailing Address - Fax:
Practice Address - Street 1:2499 FORK RIDGE RD
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-3189
Practice Address - Country:US
Practice Address - Phone:304-845-5893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVG200331630003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVG20033163000Medicaid
WVG20033163000OtherPROVIDER I D NUMBER