Provider Demographics
NPI:1306476999
Name:VANHORN, KIMBERLY DAWN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:VANHORN
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 1:1650 SW 45TH PL
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-1768
Mailing Address - Country:US
Mailing Address - Phone:541-360-8601
Mailing Address - Fax:541-758-1030
Practice Address - Street 1:1650 SW 45TH PL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1768
Practice Address - Country:US
Practice Address - Phone:541-360-8601
Practice Address - Fax:541-758-1030
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR128715Medicaid