Provider Demographics
NPI:1174632012
Name:ANDERSON, KIMBERLY RUTH (RN, C-FNP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RUTH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN, C-FNP
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:RUTH
Other - Last Name:NOREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, C-FNP
Mailing Address - Street 1:2591 SOUTH LEATON ROAD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-775-4605
Mailing Address - Fax:989-775-4680
Practice Address - Street 1:2591 SOUTH LEATON ROAD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-775-4605
Practice Address - Fax:989-775-4680
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704227621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008775960OtherBCBSM
MI500B910710OtherBCBSM
MI5008775960OtherBCBSM
MIQ75016Medicare UPIN
MIB96011128Medicare PIN
MIN55970002Medicare PIN
MI500B910710OtherBCBSM
MIP14270009Medicare PIN