Provider Demographics
NPI:1093931487
Name:GIBSON, KIMBERLY RAY (ARNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAY
Last Name:GIBSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:270-422-5000
Mailing Address - Fax:270-422-5052
Practice Address - Street 1:534 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1222
Practice Address - Country:US
Practice Address - Phone:270-422-5000
Practice Address - Fax:270-422-5052
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1081865363L00000X
KY3005150363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100006110Medicaid
KYP01233063 (KOHMG) RRMedicare PIN
KY7100006110Medicaid