Provider Demographics
NPI:1497718555
Name:STONEBURNER, KIMBERLY DAWN (LICENSED OPTICIAN)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:STONEBURNER
Suffix:
Gender:F
Credentials:LICENSED OPTICIAN
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICENSED OPTICIAN
Mailing Address - Street 1:742 NANCYS PL
Mailing Address - Street 2:
Mailing Address - City:RIDGEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29472-7000
Mailing Address - Country:US
Mailing Address - Phone:843-452-4140
Mailing Address - Fax:843-688-4192
Practice Address - Street 1:447 SOUTH RAILROAD AVE.
Practice Address - Street 2:
Practice Address - City:RIDGEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29472
Practice Address - Country:US
Practice Address - Phone:843-452-4140
Practice Address - Fax:843-688-4192
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC717156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician