Provider Demographics
NPI:1679861033
Name:PLUMMER, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:PLUMMER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 E 7TH ST STE 207
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2676
Mailing Address - Country:US
Mailing Address - Phone:541-296-5452
Mailing Address - Fax:
Practice Address - Street 1:1060 WEBBER ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3749
Practice Address - Country:US
Practice Address - Phone:541-296-5452
Practice Address - Fax:541-296-5263
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
OR24-QMHA-II-000293171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker