Provider Demographics
NPI:1932399714
Name:WASSENAAR, KIMBERLY MARIE (RT(R), RPA/RA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:WASSENAAR
Suffix:
Gender:F
Credentials:RT(R), RPA/RA
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RT(R), RPA/RA
Mailing Address - Street 1:2821 WILLOW TREE LN
Mailing Address - Street 2:UNIT D
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4785
Mailing Address - Country:US
Mailing Address - Phone:970-420-1679
Mailing Address - Fax:
Practice Address - Street 1:2821 WILLOW TREE LN
Practice Address - Street 2:UNIT D
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4785
Practice Address - Country:US
Practice Address - Phone:970-420-1679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO326783/07CO 1317247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist