Provider Demographics
NPI:1548049232
Name:STATUM, KIMBERLY (REGISTED NURSE)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:STATUM
Suffix:
Gender:F
Credentials:REGISTED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 S RANCHO DR STE 10
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3828
Mailing Address - Country:US
Mailing Address - Phone:702-268-8555
Mailing Address - Fax:702-272-2541
Practice Address - Street 1:860 S RANCHO DR STE 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3828
Practice Address - Country:US
Practice Address - Phone:702-268-8555
Practice Address - Fax:702-272-2541
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV818769163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV818769OtherSTATE OF NEVADA BOARD OF NURSING