Provider Demographics
NPI:1043323678
Name:OBERSTAR, KIMMY S (CPNP, PMHS)
Entity Type:Individual
Prefix:
First Name:KIMMY
Middle Name:S
Last Name:OBERSTAR
Suffix:
Gender:F
Credentials:CPNP, PMHS
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2910 CENTRE POINTE DRIVE
Mailing Address - Street 2:CHILDRENS HEALTH CARE
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2327
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:360 SHERMAN ST STE 200
Practice Address - Street 2:CHILDRENS SPECIALTY CLINIC PSYCHOLOGICAL SERVICES STPL
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2567
Practice Address - Country:US
Practice Address - Phone:651-220-6720
Practice Address - Fax:651-220-6707
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR1115279363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN434716100Medicaid
S47785Medicare UPIN