Provider Demographics
NPI:1043039605
Name:KOURETCHIAN, KIMBERLY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KOURETCHIAN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:KOURETCHIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10185 MYSTIC FALLS DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-9039
Mailing Address - Country:US
Mailing Address - Phone:206-708-3406
Mailing Address - Fax:
Practice Address - Street 1:1621 W CARROLL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2501
Practice Address - Country:US
Practice Address - Phone:888-510-0059
Practice Address - Fax:708-406-1629
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60593785163W00000X
WAL-308290163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse