Provider Demographics
NPI:1528468808
Name:WIXSON, KIMBERLY DUPUY
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DUPUY
Last Name:WIXSON
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 1:206 CHOUPIQUE LN
Mailing Address - Street 2:
Mailing Address - City:COTTONPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71327-3757
Mailing Address - Country:US
Mailing Address - Phone:318-876-3665
Mailing Address - Fax:318-876-2429
Practice Address - Street 1:206 CHOUPIQUE LN
Practice Address - Street 2:
Practice Address - City:COTTONPORT
Practice Address - State:LA
Practice Address - Zip Code:71327-3757
Practice Address - Country:US
Practice Address - Phone:318-876-3665
Practice Address - Fax:318-876-2429
Is Sole Proprietor?:No
Enumeration Date:2014-08-24
Last Update Date:2014-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015855183500000X
LAMA.002802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist