Provider Demographics
NPI:1811682883
Name:WALDORF, KIM
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:WALDORF
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 1:6630 S MCCARRAN BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6145
Mailing Address - Country:US
Mailing Address - Phone:775-722-0884
Mailing Address - Fax:
Practice Address - Street 1:6630 S MCCARRAN BLVD STE 6
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6145
Practice Address - Country:US
Practice Address - Phone:775-722-0884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center