Provider Demographics
NPI:1043555394
Name:MENDEZ, KIMBERLEY KAY (MSN, RN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:KAY
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:MSN, RN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-0741
Practice Address - Street 1:510 W ADAMS ST STE 150
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1789
Practice Address - Country:US
Practice Address - Phone:574-335-7900
Practice Address - Fax:574-335-0850
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28175128A363LF0000X
IN71004269A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201128480Medicaid
IN1102333420OtherANTHEM
IN000001266398OtherANTHEM
IN000001419664OtherANTHEM
IN941050092OtherMEDICARE
IN187720039OtherMEDICARE
ININ1041133OtherMEDICARE
IN000001391831OtherANTHEM
IN000001419533OtherANTHEM
IN000001419587OtherANTHEM
IN201128480Medicaid
ININ1933096OtherMEDICARE