Provider Demographics
NPI:1932316783
Name:TETRAULT, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TETRAULT
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 1:5480 WISCONSIN AVE APT 916
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-3513
Mailing Address - Country:US
Mailing Address - Phone:765-748-1213
Mailing Address - Fax:
Practice Address - Street 1:1500 FOREST GLEN RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1483
Practice Address - Country:US
Practice Address - Phone:301-754-7126
Practice Address - Fax:301-754-7127
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist