Provider Demographics
NPI:1467858019
Name:BLAND, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BLAND
Suffix:
Gender:F
Credentials:
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 2797
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-2797
Mailing Address - Country:US
Mailing Address - Phone:402-354-4230
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:402-354-3236
Practice Address - Fax:402-354-8735
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110354363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470376604-32Medicaid
IA1467858019Medicaid
NE470376604-32Medicaid