Provider Demographics
NPI:1922823541
Name:VANG, KIMBERLY NINI (NONE)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NINI
Last Name:VANG
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 76TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55444-2421
Mailing Address - Country:US
Mailing Address - Phone:612-475-0665
Mailing Address - Fax:
Practice Address - Street 1:3111 124TH AVE NW STE 150
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4581
Practice Address - Country:US
Practice Address - Phone:763-272-5877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician