Provider Demographics
NPI:1609185628
Name:DALE, KIMBERLY NICOLE (APRN)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:DALE
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:908 DUPONT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4602
Practice Address - Country:US
Practice Address - Phone:502-749-7909
Practice Address - Fax:502-637-5631
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006840363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP400043630Medicare PIN
KYP400043631Medicare PIN
KYP400043629Medicare PIN