Provider Demographics
NPI:1215162425
Name:MIMS, KIM
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:MIMS
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 1:865 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-2406
Mailing Address - Country:US
Mailing Address - Phone:203-854-6667
Mailing Address - Fax:203-549-8683
Practice Address - Street 1:865 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-2406
Practice Address - Country:US
Practice Address - Phone:203-854-6667
Practice Address - Fax:203-549-8683
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT# HCA.0000365172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker