Provider Demographics
NPI:1295946044
Name:PREVOST, KIMBERLY A
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:PREVOST
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 1:1040 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:ALGONAC
Mailing Address - State:MI
Mailing Address - Zip Code:48001-1294
Mailing Address - Country:US
Mailing Address - Phone:810-794-2083
Mailing Address - Fax:
Practice Address - Street 1:3051 COMMERCE DR
Practice Address - Street 2:STE 5
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3866
Practice Address - Country:US
Practice Address - Phone:810-385-4463
Practice Address - Fax:810-385-8875
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care