Provider Demographics
NPI:1831619683
Name:SANFORD, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SANFORD
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 1:100 W 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2452
Mailing Address - Country:US
Mailing Address - Phone:931-528-1575
Mailing Address - Fax:931-528-9803
Practice Address - Street 1:100 W 4TH ST STE 200
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2452
Practice Address - Country:US
Practice Address - Phone:931-528-1575
Practice Address - Fax:931-528-9803
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80867231H00000X
TN1969231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist