Provider Demographics
NPI:1578850905
Name:CRISS, KIMBERLEY DENISE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:DENISE
Last Name:CRISS
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 1:711 KASKASKIA ST
Mailing Address - Street 2:
Mailing Address - City:MENARD
Mailing Address - State:IL
Mailing Address - Zip Code:62259-1000
Mailing Address - Country:US
Mailing Address - Phone:618-826-5071
Mailing Address - Fax:
Practice Address - Street 1:5031 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-3453
Practice Address - Country:US
Practice Address - Phone:618-212-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006842363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4903007Medicare PIN