Basic Information
| Provider Information | |||||||||
| NPI: | 1114249117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 US HIGHWAY 61 NORTH | ||||||||
| Address2: | |||||||||
| City: | HAYTI | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733592600 | ||||||||
| FaxNumber: | 5733591103 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 HIGHWAY V V | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738885925 | ||||||||
| FaxNumber: | 5738889365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2010 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2007032845 | MO | Y | Nursing Service Providers | Registered Nurse |
No ID Information.