Provider Demographics
NPI:1073174199
Name:RUTLAND, KIMBERLY AMELIA (WHNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:AMELIA
Last Name:RUTLAND
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 SIXTH AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-5396
Mailing Address - Country:US
Mailing Address - Phone:208-265-6252
Mailing Address - Fax:208-265-8214
Practice Address - Street 1:810 SIXTH AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-5396
Practice Address - Country:US
Practice Address - Phone:208-265-6252
Practice Address - Fax:208-265-8214
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID78336363LX0001X
WAAP61044089363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2171876Medicaid