Provider Demographics
NPI:1598378986
Name:KIRK, NICOLE DEE (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DEE
Last Name:KIRK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67216-1739
Mailing Address - Country:US
Mailing Address - Phone:316-993-8123
Mailing Address - Fax:
Practice Address - Street 1:4747 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67216-1739
Practice Address - Country:US
Practice Address - Phone:316-529-3084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSF01200572363LF0000X
KS5379282012363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201337300AMedicaid
KS53-79282-012OtherKANSAS STATE BOARD OF NURSING
KS112613OtherKSBN-RN
KS1598378986OtherNPI