Provider Demographics
NPI:1376549543
Name:KOENIGSMARK, KYLI W (ARNP)
Entity Type:Individual
Prefix:
First Name:KYLI
Middle Name:W
Last Name:KOENIGSMARK
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:PO BOX 636961
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6961
Mailing Address - Country:US
Mailing Address - Phone:513-981-5130
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:1532 LONE OAK RD
Practice Address - Street 2:STE 405
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7913
Practice Address - Country:US
Practice Address - Phone:270-441-4300
Practice Address - Fax:240-441-4370
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003337363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78005220Medicaid
KY78005220Medicaid
KY00931020Medicare PIN