Provider Demographics
NPI:1609397462
Name:ALTIZER, KIMBERLY DIANE (NP-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:ALTIZER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 CARRIAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588-4573
Mailing Address - Country:US
Mailing Address - Phone:434-907-5614
Mailing Address - Fax:
Practice Address - Street 1:104 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:BROOKNEAL
Practice Address - State:VA
Practice Address - Zip Code:24528-2643
Practice Address - Country:US
Practice Address - Phone:434-376-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174933363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner