Provider Demographics
NPI:1952754608
Name:WAITE, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WAITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:CHARLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 SW B AVE
Mailing Address - Street 2:APT 7-24
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-3828
Mailing Address - Country:US
Mailing Address - Phone:580-340-3950
Mailing Address - Fax:
Practice Address - Street 1:1401 SW B AVE
Practice Address - Street 2:APT 7-24
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3828
Practice Address - Country:US
Practice Address - Phone:580-340-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator