Provider Demographics
NPI:1265511489
Name:ETHERINGTON, KIMBERLY ELIZABETH (PA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ELIZABETH
Last Name:ETHERINGTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1410 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-2606
Mailing Address - Country:US
Mailing Address - Phone:641-357-2191
Mailing Address - Fax:641-357-6020
Practice Address - Street 1:1410 6TH AVE S
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-2606
Practice Address - Country:US
Practice Address - Phone:641-357-2191
Practice Address - Fax:641-357-6020
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001109363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA45658OtherWELLMARK
IA36657OtherWELLMARK
IA36657OtherWELLMARK