Provider Demographics
NPI:1073523478
Name:HANSEN, KIMBERLY A (CNP)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:A
Last Name:HANSEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1974
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1974
Mailing Address - Country:US
Mailing Address - Phone:575-623-1303
Mailing Address - Fax:575-622-1303
Practice Address - Street 1:109 W BLAND ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5708
Practice Address - Country:US
Practice Address - Phone:575-623-1303
Practice Address - Fax:575-622-1303
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR33452363L00000X
NMCNP00691363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR33452OtherSTATE LICENSE NUMBER