1679573794 NPI number — DR. KIMBERLY J ANDRESEN AU.D CCC-A

Table of content: DR. KIMBERLY J ANDRESEN AU.D CCC-A (NPI 1679573794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679573794 NPI number — DR. KIMBERLY J ANDRESEN AU.D CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDRESEN
Provider First Name:
KIMBERLY
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D CCC-A
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:
1679573794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2421 WEST FAIDLEY AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68803-4328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-384-2101
Provider Business Mailing Address Fax Number:
308-381-4787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2421 WEST FAIDLEY AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803-4328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-384-2101
Provider Business Practice Location Address Fax Number:
308-381-4787
Provider Enumeration Date:
07/29/2005

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: 231H00000X , with the licence number:  2201001204 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237600000X , with the licence number: 288 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 237600000X , with the licence number: 108 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00014101 . This is a "RAILROAD-LYNCHBURG" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 47073801200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 540964595 . This is a "PRIMARY PHYSICIAN CARE-DA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541361858 . This is a "PRIMARY PHYSICIAN CARE-LY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10025275800 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 463627 . This is a "ANTHEM OF VA - LYN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541361858 . This is a "PIEDMONTCOMMUNITYHLTHPLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9451510 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00014119 . This is a "RAILROAD-DANVILLE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 248044 . This is a "ANTHEM OF VA - DANVILLE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9451501 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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