Provider Demographics
NPI:1679573794
Name:ANDRESEN, KIMBERLY J (AUD CCC-A)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:J
Last Name:ANDRESEN
Suffix:
Gender:F
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 WEST FAIDLEY AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4328
Mailing Address - Country:US
Mailing Address - Phone:308-384-2101
Mailing Address - Fax:308-381-4787
Practice Address - Street 1:2421 WEST FAIDLEY AVENUE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4328
Practice Address - Country:US
Practice Address - Phone:308-384-2101
Practice Address - Fax:308-381-4787
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001204231H00000X
NE288237600000X
NE108237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00014101OtherRAILROAD-LYNCHBURG
NE47073801200Medicaid
VA540964595OtherPRIMARY PHYSICIAN CARE-DA
VA541361858OtherPRIMARY PHYSICIAN CARE-LY
NE10025275800Medicaid
VA463627OtherANTHEM OF VA - LYN
VA541361858OtherPIEDMONTCOMMUNITYHLTHPLAN
VA9451510Medicaid
VAP00014119OtherRAILROAD-DANVILLE
VA248044OtherANTHEM OF VA - DANVILLE
VA9451501Medicaid
VA463627OtherANTHEM OF VA - LYN
VA001403A01Medicare ID - Type UnspecifiedMEDICARE-TRAILBLAZER-LYN
NE231H00000XMedicare UPIN
NE086319002Medicare PIN
VA541361858OtherPIEDMONTCOMMUNITYHLTHPLAN
VA9451510Medicaid