Provider Demographics
NPI:1053818450
Name:STEVENSON, KIMBERLY CARLY NICOLE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:CARLY NICOLE
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:CARLY NICOLE
Other - Last Name:HURT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:908 SCARBRO RD
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-8837
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:
Practice Address - Street 1:908 SCARBRO RD
Practice Address - Street 2:
Practice Address - City:SCARBRO
Practice Address - State:WV
Practice Address - Zip Code:25917-8837
Practice Address - Country:US
Practice Address - Phone:304-469-2905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH467275163W00000X
WV97400163W00000X
WV108428363LF0000X
VA0024180856363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse