Provider Demographics
NPI:1518281757
Name:NIEBRUGGE, KIMBERLY A (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:NIEBRUGGE
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 1:1029 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1238
Mailing Address - Country:US
Mailing Address - Phone:618-283-4469
Mailing Address - Fax:618-283-4767
Practice Address - Street 1:1029 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1238
Practice Address - Country:US
Practice Address - Phone:618-283-4469
Practice Address - Fax:618-283-4767
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200932407363L00000X
IL209-007693363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner