Provider Demographics
NPI:1811458094
Name:DETHEROW, KIMBERLY (APRN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DETHEROW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24015 AUGUSTA FALLS LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-4276
Mailing Address - Country:US
Mailing Address - Phone:832-221-7098
Mailing Address - Fax:
Practice Address - Street 1:126 MAIN PLZ
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2745
Practice Address - Country:US
Practice Address - Phone:888-365-6271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141095363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health