1114929742 NPI number — KIMBERLY A ROBERTSON CRNP

Table of content: KIMBERLY A ROBERTSON CRNP (NPI 1114929742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114929742 NPI number — KIMBERLY A ROBERTSON CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
KIMBERLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
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:
1114929742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 MARIARDEN RD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
DADEVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36853-6254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-825-7871
Provider Business Mailing Address Fax Number:
256-827-0808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MARIARDEN RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
DADEVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36853-6254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-825-3280
Provider Business Practice Location Address Fax Number:
256-827-0808
Provider Enumeration Date:
08/12/2005

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: 363L00000X , with the licence number:  9199035 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 1-037958 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 540003420 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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