Provider Demographics
NPI:1437415551
Name:KIMBROUGH, CHERIE LANHAM (CPNP)
Entity Type:Individual
Prefix:
First Name:CHERIE
Middle Name:LANHAM
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL PLAZA DR
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367
Mailing Address - Country:US
Mailing Address - Phone:636-625-5300
Mailing Address - Fax:636-625-5376
Practice Address - Street 1:100 MEDICAL PLAZA DR
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367
Practice Address - Country:US
Practice Address - Phone:636-625-5300
Practice Address - Fax:636-625-5376
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012008398363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507602605Medicaid