Provider Demographics
NPI:1649561788
Name:BONVILLAIN, KIMBERLY (FNP-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BONVILLAIN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4068 DENNY LN
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:KY
Mailing Address - Zip Code:41091-7551
Mailing Address - Country:US
Mailing Address - Phone:985-414-0570
Mailing Address - Fax:
Practice Address - Street 1:625 CHESTNUT DR
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:KY
Practice Address - Zip Code:41094-7845
Practice Address - Country:US
Practice Address - Phone:859-485-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-24
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4008581363LF0000X
OH35357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily