Provider Demographics
NPI:1689310062
Name:HOLTON, KIMBERLEY LISA
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:LISA
Last Name:HOLTON
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 1:17549 ASHTON UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-8351
Mailing Address - Country:US
Mailing Address - Phone:304-208-1311
Mailing Address - Fax:
Practice Address - Street 1:17549 ASHTON UPLAND RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-8351
Practice Address - Country:US
Practice Address - Phone:304-208-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV36572364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV550675666Medicaid