Basic Information
| Provider Information | |||||||||
| NPI: | 1326204892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRICHS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LYNETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICHARDS | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | LYNETTE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1100 WILFORD HALL LOOP | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782365638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102924046 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 333 N. SANTA ROSA STREET | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107042011 | ||||||||
| FaxNumber: | 6082657957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A111666 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 56993-20 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | Q1163 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.