Provider Demographics
NPI:1730242769
Name:HANSON, KIMM GLORIA
Entity type:Individual
Prefix:MS
First Name:KIMM
Middle Name:GLORIA
Last Name:HANSON
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 1:2490 W YOWELL CT UNIT 49
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-1735
Mailing Address - Country:US
Mailing Address - Phone:928-539-9298
Mailing Address - Fax:
Practice Address - Street 1:2490 W YOWELL CT UNIT 49
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-1735
Practice Address - Country:US
Practice Address - Phone:928-539-9298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11133385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ085948Medicaid