Provider Demographics
NPI:1497786933
Name:PHILLIPS, KIMBERLY ANNE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7670 W SAHARA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-2751
Mailing Address - Country:US
Mailing Address - Phone:702-457-7400
Mailing Address - Fax:702-457-7401
Practice Address - Street 1:7670 W SAHARA AVE STE 2
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2751
Practice Address - Country:US
Practice Address - Phone:702-457-7400
Practice Address - Fax:702-457-7401
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3515178900363LA2100X
UT3515174405363LA2100X
NVAPN001449363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005004619-28OtherANCC NATIONAL CREDENTIAL
UT351517-4405OtherAPRN
NVCS20659OtherNEVADA PHARMACY LICENSE
NV1497786933Medicaid
NVAPRN001449OtherNEVADA APRN LICENSE
UT351517-8900OtherUTAH CONTROLLED SUBSTANCE
MP1302330OtherNATIONAL DEA
NV1497786933Medicaid