Provider Demographics
NPI:1407160013
Name:KERSHNER, KIMBERLY S (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:KERSHNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:S
Other - Last Name:BUTRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-3064
Practice Address - Fax:417-820-8862
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO146907363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1407160013Medicaid
431560263OtherTRICARE WEST
AR183615758Medicaid
AR183615758Medicaid