Provider Demographics
NPI:1649325192
Name:STEVENS, KIMBERLY
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:STEVENS
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 1:2731 OLD SCHOOL HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-9421
Mailing Address - Country:US
Mailing Address - Phone:928-536-2617
Mailing Address - Fax:
Practice Address - Street 1:682 W SCHOOL BUS LN
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5262
Practice Address - Country:US
Practice Address - Phone:928-536-4156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN067159163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ552423Medicaid