Provider Demographics
NPI:1659664852
Name:PETTINELLI, KIMBERLY DAWN (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:PETTINELLI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2935
Mailing Address - Country:US
Mailing Address - Phone:218-262-3441
Mailing Address - Fax:218-362-6908
Practice Address - Street 1:3605 MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2935
Practice Address - Country:US
Practice Address - Phone:218-262-3441
Practice Address - Fax:218-362-6908
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN129504-7363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1659664852Medicaid
MN500006831OtherMN MEDICARE NUMBER PTAN