Provider Demographics
NPI:1295413243
Name:EDMOND, KIMILY (BS)
Entity type:Individual
Prefix:
First Name:KIMILY
Middle Name:
Last Name:EDMOND
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11694
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77293-1694
Mailing Address - Country:US
Mailing Address - Phone:346-552-0883
Mailing Address - Fax:
Practice Address - Street 1:1000 FM 1960 RD W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2508
Practice Address - Country:US
Practice Address - Phone:346-552-0883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR256789332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies