Provider Demographics
NPI:1770290942
Name:ANTOINE, KIMBERLY NICOLE (SLP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:ANTOINE
Suffix:
Gender:F
Credentials:SLP
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 1165
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767-1165
Mailing Address - Country:US
Mailing Address - Phone:225-268-1544
Mailing Address - Fax:
Practice Address - Street 1:5550 THOMAS RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70811-7370
Practice Address - Country:US
Practice Address - Phone:225-268-1544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist