Basic Information
| Provider Information | |||||||||
| NPI: | 1255569760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPILLER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LOVELL | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1212 S LILLY ST | ||||||||
| Address2: | |||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723155310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707639226 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1510 BYRUM RD | ||||||||
| Address2: | |||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723158033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705322600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 06/24/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 161010724 | 05 | AR | MEDICAID |