Provider Demographics
NPI:1194550053
Name:KRUEGER, KIMBERLY ANN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:KRUEGER
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 1:407 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6800
Mailing Address - Country:US
Mailing Address - Phone:208-790-0303
Mailing Address - Fax:
Practice Address - Street 1:407 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6800
Practice Address - Country:US
Practice Address - Phone:208-790-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOAN29FSQCC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier