Provider Demographics
NPI:1285817122
Name:STOVER, KIMBERLY CARLSON (NP-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CARLSON
Last Name:STOVER
Suffix:
Gender:F
Credentials:NP-C
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 11208
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-1208
Mailing Address - Country:US
Mailing Address - Phone:928-541-1312
Mailing Address - Fax:928-541-0002
Practice Address - Street 1:3190 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7131
Practice Address - Country:US
Practice Address - Phone:928-541-1312
Practice Address - Fax:928-541-0002
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN148475163W00000X
AZAP2910363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ527011Medicaid