Provider Demographics
NPI:1558798371
Name:MUNNEKE, KIMBERLY (NP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:MUNNEKE
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2227 W BASELINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1250
Mailing Address - Country:US
Mailing Address - Phone:602-254-6640
Mailing Address - Fax:602-254-6164
Practice Address - Street 1:2227 W BASELINE RD STE 101
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1250
Practice Address - Country:US
Practice Address - Phone:602-254-6640
Practice Address - Fax:602-254-6164
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ219630363LF0000X
NC5007649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1558798371Medicaid
NC1558798371Medicaid