Provider Demographics
NPI:1467443036
Name:PENLAND, KIMBERLY S (FNP-BC, PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:PENLAND
Suffix:
Gender:F
Credentials:FNP-BC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5110 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5720
Practice Address - Country:US
Practice Address - Phone:260-469-6605
Practice Address - Fax:260-969-3066
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001183A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN500024449OtherRR MEDICARE
IN000000368990OtherANTHEM
IN200329110Medicaid
IN500024449OtherRR MEDICARE
IN188220BMedicare PIN