Basic Information
| Provider Information | |||||||||
| NPI: | 1932316783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TETRAULT | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5480 WISCONSIN AVE APT 916 | ||||||||
| Address2: | |||||||||
| City: | CHEVY CHASE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208153513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657481213 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 FOREST GLEN RD | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209101483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017547126 | ||||||||
| FaxNumber: | 3017547127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 17763 | MD | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.