Provider Demographics
NPI:1073851291
Name:TUTTLE, KIMBERLEY
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:TUTTLE
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 1:7005 COLD FOOT CT
Mailing Address - Street 2:
Mailing Address - City:SALCHA
Mailing Address - State:AK
Mailing Address - Zip Code:99714-9713
Mailing Address - Country:US
Mailing Address - Phone:907-488-3089
Mailing Address - Fax:
Practice Address - Street 1:1867 AIRPORT WAY STE 225
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4062
Practice Address - Country:US
Practice Address - Phone:907-455-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPC00915Medicaid