Provider Demographics
NPI:1982909800
Name:SHAMBLIN, KIMALISA KAY (BA, RT(R)(CT), RVT)
Entity Type:Individual
Prefix:
First Name:KIMALISA
Middle Name:KAY
Last Name:SHAMBLIN
Suffix:
Gender:F
Credentials:BA, RT(R)(CT), RVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 WILDLIFE WAY
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-5193
Mailing Address - Country:US
Mailing Address - Phone:304-206-1420
Mailing Address - Fax:
Practice Address - Street 1:428 DIVISION ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1469
Practice Address - Country:US
Practice Address - Phone:304-766-9617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1540246XS1301X, 247100000X, 2471C3401X, 2471C3402X, 2471S1302X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography