1215171251 NPI number — DR. KIMBERLY CECIL-RIDDLE DNP, APRN, FNP-BC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215171251 NPI number — DR. KIMBERLY CECIL-RIDDLE DNP, APRN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CECIL-RIDDLE
Provider First Name:
KIMBERLY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DNP, APRN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215171251
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 WALTER GARRETT LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK GROVE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-640-5821
Provider Business Mailing Address Fax Number:
844-270-5587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 WALTER GARRETT LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK GROVE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-640-5821
Provider Business Practice Location Address Fax Number:
844-270-5587
Provider Enumeration Date:
04/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  3004526 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Q020269 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: K202700 . This is a "MEDICARE: INDIVIDUAL" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 474415234 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100395690 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: K202701 . This is a "MEDICARE GROUP (ST. MICHAEL'S)" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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