Provider Demographics
NPI:1043613888
Name:KEARNEY, KIMBERLY DIANE (DNP)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:DIANE
Last Name:KEARNEY
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2736
Mailing Address - Country:US
Mailing Address - Phone:307-332-9577
Mailing Address - Fax:307-332-3106
Practice Address - Street 1:134 4TH AVE W
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1018
Practice Address - Country:US
Practice Address - Phone:505-238-8639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY34454.1357363LF0000X
ID53414363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily