Provider Demographics
NPI:1780141119
Name:PEMBERTON, KIM (RN)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 WINDROW CT # 90812
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-2377
Mailing Address - Country:US
Mailing Address - Phone:810-287-9888
Mailing Address - Fax:
Practice Address - Street 1:1034 WINDROW CT # 90812
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-2377
Practice Address - Country:US
Practice Address - Phone:810-287-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704240308163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse