Provider Demographics
NPI:1194356055
Name:CUSHMAN, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CUSHMAN
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 1:1034 W ANN ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1502
Mailing Address - Country:US
Mailing Address - Phone:734-667-5152
Mailing Address - Fax:734-667-2579
Practice Address - Street 1:30488 MILFORD RD
Practice Address - Street 2:
Practice Address - City:NEW HUDSON
Practice Address - State:MI
Practice Address - Zip Code:48165-8583
Practice Address - Country:US
Practice Address - Phone:484-374-6252
Practice Address - Fax:248-437-4665
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program