Provider Demographics
NPI:1376952457
Name:BLUM, KIMBERLY MICHELLE (APRN, AGCNS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:BLUM
Suffix:
Gender:F
Credentials:APRN, AGCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 W BEN WHITE BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7524
Mailing Address - Country:US
Mailing Address - Phone:512-326-5440
Mailing Address - Fax:512-326-8660
Practice Address - Street 1:2315 W BEN WHITE BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7524
Practice Address - Country:US
Practice Address - Phone:512-326-5440
Practice Address - Fax:512-326-8660
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126079364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX339976801Medicaid
TX339976801Medicaid