Provider Demographics
NPI:1649830225
Name:HANSON, KIMBERLY DAWN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:HANSON
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 1:1246 NURSERY HILL LN
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55112-5712
Mailing Address - Country:US
Mailing Address - Phone:651-210-4004
Mailing Address - Fax:
Practice Address - Street 1:1884 RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1747
Practice Address - Country:US
Practice Address - Phone:651-287-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6479363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health