Provider Demographics
NPI:1316480650
Name:KOSA, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KOSA
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 1:525 CENTURY CT
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1091
Mailing Address - Country:US
Mailing Address - Phone:276-920-1748
Mailing Address - Fax:
Practice Address - Street 1:525 CENTURY CT
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1091
Practice Address - Country:US
Practice Address - Phone:276-920-1748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003858235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist