Provider Demographics
NPI:1386295251
Name:PICKETT-HELON, KIM M
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:PICKETT-HELON
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 1:6800 WOODBINE AVE APT 50
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-4047
Mailing Address - Country:US
Mailing Address - Phone:916-271-9705
Mailing Address - Fax:
Practice Address - Street 1:6800 WOODBINE AVE APT 50
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95822-4047
Practice Address - Country:US
Practice Address - Phone:916-271-9705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA258251734Medicaid