Provider Demographics
NPI:1538681754
Name:CALDERON, KIMBERLY (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CALDERON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 N FOURTH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-0038
Mailing Address - Country:US
Mailing Address - Phone:903-757-3881
Mailing Address - Fax:903-757-5948
Practice Address - Street 1:1900 S WASHINGTON AVE STE E
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-6845
Practice Address - Country:US
Practice Address - Phone:903-503-7330
Practice Address - Fax:903-503-7336
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX134399363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX377233702Medicaid