Provider Demographics
NPI:1588626592
Name:HARRIS, KIMBERLY PATRICE (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:PATRICE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:PATRICE
Other - Last Name:HARRISNP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:551 LINN ST
Mailing Address - Street 2:STE 150
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1595
Mailing Address - Country:US
Mailing Address - Phone:269-686-5800
Mailing Address - Fax:269-686-5896
Practice Address - Street 1:551 LINN ST
Practice Address - Street 2:STE 150
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1595
Practice Address - Country:US
Practice Address - Phone:269-686-5800
Practice Address - Fax:269-686-5896
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704164659363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588626592Medicaid
MI1588626592Medicaid
MIOF71000OtherBCBS
MIN38050004Medicare ID - Type Unspecified
MI1588626592Medicaid