Provider Demographics
NPI:1508306952
Name:KING, KIMBERLY JANEAN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JANEAN
Last Name:KING
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 ASH ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1370
Mailing Address - Country:US
Mailing Address - Phone:618-530-3463
Mailing Address - Fax:
Practice Address - Street 1:610 ASH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1370
Practice Address - Country:US
Practice Address - Phone:618-530-3463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-05
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016044352363L00000X, 364SF0001X
IL209017430363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health