Provider Demographics
NPI:1023506102
Name:WEBB, KIMMIE
Entity type:Individual
Prefix:
First Name:KIMMIE
Middle Name:
Last Name:WEBB
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 1:4216 ORION AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-3222
Mailing Address - Country:US
Mailing Address - Phone:702-498-9248
Mailing Address - Fax:
Practice Address - Street 1:4216 ORION AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-3222
Practice Address - Country:US
Practice Address - Phone:702-498-9248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2000088673OtherDRIVER'S LICENSE