Provider Demographics
NPI:1063669497
Name:EARL, KIM A (APRN, PMHNP, FNP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:EARL
Suffix:
Gender:F
Credentials:APRN, PMHNP, FNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:EARL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN, PMHNP, FNP-BC
Mailing Address - Street 1:1124 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2406
Mailing Address - Country:US
Mailing Address - Phone:217-523-3143
Mailing Address - Fax:217-523-1513
Practice Address - Street 1:1124 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2406
Practice Address - Country:US
Practice Address - Phone:217-523-3143
Practice Address - Fax:217-523-1513
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007155363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208260014Medicare PIN