Provider Demographics
NPI:1699597260
Name:RICHARDSON, KIM NMI
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:NMI
Last Name:RICHARDSON
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 1:1145 HUDSON RD APT 228
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-4326
Mailing Address - Country:US
Mailing Address - Phone:651-503-6573
Mailing Address - Fax:
Practice Address - Street 1:1145 HUDSON RD APT 228
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-4326
Practice Address - Country:US
Practice Address - Phone:651-503-6573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker