Provider Demographics
NPI:1154448561
Name:DOUGLAS, KIMBERLY BROOKE
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:BROOKE
Last Name:DOUGLAS
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 1:132 MCKENZIE DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-4327
Mailing Address - Country:US
Mailing Address - Phone:580-772-2831
Mailing Address - Fax:
Practice Address - Street 1:90 NORTH THIRTY FIRST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601
Practice Address - Country:US
Practice Address - Phone:580-323-6021
Practice Address - Fax:580-323-0828
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator