Provider Demographics
NPI:1427665249
Name:MERRELL, KIMBERLY DAWN
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:MERRELL
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 1:1197 SW LINDEN LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-9042
Mailing Address - Country:US
Mailing Address - Phone:971-239-3229
Mailing Address - Fax:
Practice Address - Street 1:4356 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-3914
Practice Address - Country:US
Practice Address - Phone:503-689-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25425225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist